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Changes to the school food and physical activity environment after guideline implementation in British… Watts, Allison W; Mâsse, Louise C; Naylor, Patti-Jean Apr 14, 2014

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RESEARCH Open AccessChanges to the school food and physical activityenvironment after guideline implementation inBritish Columbia, CanadaAllison W Watts1, Louise C Mâsse1,3* and Patti-Jean Naylor2AbstractBackground: High rates of childhood obesity have generated interest among policy makers to improve the schoolfood environment and increase students’ levels of physical activity. The purpose of this study was to examineschool-level changes associated with implementation of the Food and Beverage Sales in Schools (FBSS) and DailyPhysical Activity (DPA) guidelines in British Columbia, Canada.Methods: Elementary and middle/high school principals completed a survey on the school food and physicalactivity environment in 2007–08 (N = 513) and 2011–12 (N = 490). Hierarchical mixed effects regression was used toexamine changes in: 1) availability of food and beverages; 2) minutes per day of Physical Education (PE); 3) deliverymethod of PE; and 4) school community support. Models controlled for school enrollment and community type,education and income.Results: After policy implementation was expected, more elementary schools provided access to fruits andvegetables and less to 100% fruit juice. Fewer middle/high schools provided access to sugar-sweetened beverages,French fries, baked goods, salty snacks and chocolate/candy. Schools were more likely to meet 150 min/week of PEfor grade 6 students, and offer more minutes of PE per week for grade 8 and 10 students including changes to PEdelivery method. School community support for nutrition and physical activity policies increased over time.Conclusion: Positive changes to the school food environment occurred after schools were expected to implementthe FBSS and DPA guidelines. Reported changes to the school environment are encouraging and provide supportfor guidelines and policies that focus on increasing healthy eating and physical activity in schools.Keywords: School policy, School food availability, Physical education, ImplementationIntroductionOver the course of the school day, children have manyopportunities to purchase less healthful food and bever-ages [1-4]. Food and beverages commonly sold at schoolinclude soda, pizza, hamburgers, French fries and junkfood [1,5,6] and the availability of these foods and bever-ages has been associated with both greater consumptionwhile at school [3,7] and student’s body weight [8]. Con-currently, children do not achieve adequate levels ofphysical activity for good health, [9,10] and physicalactivity while at school has declined over the past severaldecades [11-13]. Furthermore, children who participatein physical education (PE) classes [14,15] or attendschools that offer daily PE [16] achieve higher levels ofphysical activity than those who do not participate.Given heightened concern over rising rates of childhoodobesity, the school environment has been promoted as asetting where healthy eating and physical activity can beimproved [17].To address population-wide childhood obesity, a grow-ing number of jurisdictions in the U.S., Canada, andabroad have introduced school policies that restrict thetypes of foods and beverages sold and increase time re-quirements for physical activity at school. Several studieshave found that the implementation of school nutritional* Correspondence: lmasse@cfri.ubc.ca1School of Population and Public Health, University of British Columbia,F508-4480 Oak Street, Vancouver, British Columbia V6H 3V4, Canada3Department of Pediatrics, University of British Columbia, F508-4480 OakStreet, Vancouver, BC V6H 3V4, CanadaFull list of author information is available at the end of the article© 2014 Watts et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Watts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50http://www.ijbnpa.org/content/11/1/50policies has restricted the availability [18-21] and con-sumption [22,23] of less healthful food at school, whileothers have found little or no association [3,4]. In theUS, schools in states with stronger PE laws providedmore minutes of PE per week among elementary andmiddle schools [24,25], but not in high schools [25].Studies have also found that successful adoption of thesepolicies requires support from members of the schoolcommunity such as teachers, principals, students andparents [26,27]. Given the importance of reducing child-hood obesity and the increase in school policies to ad-dress this problem, evaluation of school nutrition andphysical activity policies is urgently needed [28].The purpose of this study was to examine school-levelchanges associated with the implementation of the Foodand Beverage Sales in British Columbia (BC, Canada)Schools (FBSS) and Daily Physical Activity (DPA) guide-lines in BC. The FBSS guidelines, initially released in2005 by the provincial Ministry of Health and Education,provided minimum nutrition standards for food andbeverages sold in school vending machines, cafeterias,snack bars as well as sold as part of fundraising activitiesor at special events [29]. Essentially, the FBSS guidelinesrestrict what food and beverages can be sold in schoolsby eliminating high sugar and fat food (e.g. regular chips,candy, pop) entirely and replacing certain food withlower fat, sugar, and salt versions and whole grain substi-tutes (e.g. whole wheat crust on pizza, baked chips, dietpop) (see FBSS guidelines [29]). In 2007, the FBSS guide-lines were revised to align with the Canada’s Food guide[30] and to accelerate implementation of the guidelinesby the 2008–09 school year, except for elementaryschools where implementation was expected by Januaryof 2008. The DPA guidelines require all schools in BC tooffer 30 minutes of daily physical activity in grades K-9and in grades 10–12 they must document and report150 minutes per week of physical activity (e.g., throughinstructional or non-instructional opportunities) (see DPAguidelines [31]). School districts were responsible for devel-oping their own policies and procedures to track imple-mentation of the DPA guidelines [31]. Both guidelineswere disseminated through established communicationchannels, including presentations at meetings, brochuresand websites. While schools were expected to implementboth the FBSS and DPA guidelines, at the time of thisstudy there were no formal mechanism in place to enforceimplementation. The specific aims for this study were todetermine whether the school environment changed whenthe FBSS and DPA guidelines were expected to be fullyimplemented in the 2008–09 school year. We hypothe-sized that schools would provide fewer unhealthy optionsand more healthy options, increase the minutes of PE thatstudents receive per week, change PE delivery from halfsemester to linear system (i.e., offering PE all versus halfthe year) and report more stakeholder support for nutri-tion and physical activity policies.MethodsSampleIn the 2007–08 and 2011–12 school years, all schoolprincipals in BC within districts that provided approvalwere invited to complete a questionnaire on physicalactivity and nutrition policies and practices at theirschool. School district approval was received from 43districts in 2007–08 (73% response rate) and 49 dis-tricts in 2011–12 (83% response rate). Independent,Alternate, Francophone and First Nation schools wereexcluded because this questionnaire was not designedto measure the unique contexts experienced at thoseschools. In 2007–08, complete surveys were returnedfrom 384 elementary, 118 middle/high and 11 mixedgrade schools (48% response rate). Surveys were com-pleted by the principal (90%), vice-principal (7%),teacher (1%) or other staff member (2%). These schoolshad an average enrollment of 403 students, 60% werelocated in census metropolitan areas, and schools werefrom communities with 32% post-secondary educationand a median household income of $60,356. In 2011–12,complete surveys were returned from 351 elementary, 125middle/high and 14 mixed grade schools (49% responserate). Surveys were completed by the principal (93%), viceprincipal (5%) or a teacher (2%). These schools had anaverage enrollment of 410 students, 51% were located incensus metropolitan areas, and schools were from com-munities with 32% post-secondary education and a me-dian household income of $58,757. Among this sample,151 elementary, 50 middle/high and 2 mixed gradeschools completed both the 2007–08 and 2011–12 sur-veys. Note that our first data collection (in 2007–08) oc-curred before schools were expected to fully implementthe FBSS and DPA guidelines in the 2008–09 school year,with the exception of elementary schools which were ex-pected to implement the FBSS guidelines in January of2008. From our qualitative interviews, we know thatschools were still struggling to implement the FBSS guide-lines by the 2010–11 school year and that implementationlags over time [26]. While we acknowledge this overlap, itis likely that minimal changes had occurred at our firstdata collection although some changes could have beeninitiated.ProceduresUpon district approval, school principals were mailed apackage that included an invitation letter, a consent formand a hard copy of the questionnaire to be completedand returned using a pre-paid envelope. To increase re-sponse rates, schools that had not returned the question-naire within 4–6 weeks were mailed a second package asWatts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 2 of 10http://www.ijbnpa.org/content/11/1/50well as an email with the option to complete the surveyonline. Schools also received reminder phone calls byproject staff after each mailing. Principals who com-pleted the survey received a $10 gift card. This studywas approved by the University of British Columbia andthe University of Victoria Research Ethics Board.MeasuresFood and beverage availabilityPrincipals completed questions from the School HealthPolicies and Programs Study (SHPPS) [32] that asked ifstudents had access to the following 11 food and bever-age items from the school cafeteria, vending machine orsnack bar/store during school hours in a typical week:[1] sugar sweetened beverages (e.g. pop, iced tea, sportsdrinks or fruit drinks that are not 100% fruit juice); [2]100% fruit juice; [3] fruit; [4] baked goods (e.g. cookies,crackers, cakes, pastries); [5] low-fat baked goods; [6]French fries [7] salad (lettuce, vegetable, or bean salads),referred to as “vegetables” for this analysis; [8] pizza,hamburgers or hotdogs; [9] salty snacks (e.g. potatochips, cheese puffs); [10] low-fat salty snacks (e.g. pret-zels, baked chips); and [11] chocolate candy. Each cat-egory was coded as 1 = available; 0 = not available. In2007–08 principals were given a list and told to checkall that apply. In 2011–12, principals were asked to re-spond (yes/no) on the availability of each item. Add-itional items were also added to assess if pizzas wereserved on a whole wheat crust with low-fat cheese and ifhotdogs/hamburgers were served on a whole wheat bunwith low-fat meat based on the new guidelines for thesefood items.Minutes of physical educationMinutes of PE per week received by grade 6 studentswas measured as a dichotomous variable. In 2007–08,principals received two versions of this item, the firstversion (n = 331) provided response categories of: 30–59,60–89, 90–119, 120–149, >150 minutes per week; whilethe second version (n = 182) asked the principals towrite in the number of PE minutes students in grade 6received per week. In 2011–12, principals reported thenumber of days that grade 6 students received PE, theduration of each PE class and if PE was delivered on asemester system. In all versions, minutes of PE per weekwas dichotomized where 0 = <150 minutes per week and1 = ≥150 minutes per week to correspond with the BCguidelines.Minutes of PE per week received by grade 8 and 10students was measured as a continuous variable. In2007–08 principals were asked to fill in the minutes perweek that grade 8 and 10 students received, separately.In 2011–12, minutes of PE was calculated by multiplyingthe reported number of days that students received PEby the reported length in minutes of each PE class forgrades 8 and 10 separately. If principals reported that PEwas delivered on a semester system, the total was di-vided by 2 to approximate PE received over the entireschool year.Delivery format of physical educationThe delivery method of PE for grade 8 and 10 studentswas assessed with a dichotomous variable: 0 = deliveredin one semester; 1 = PE delivered linearly. In 2007–08,principals were phoned to confirm the delivery methodof PE to grade 8 and 10 students. In 2011–12, an itemfor each grade asked whether PE was required all or partof the year with response options of: not applicable, allyear, part of the school year (i.e. 1 semester), or notscheduled.Stakeholder supportPrincipal, staff, parent and student support for nutritionpolicies was assessed with 4-items, e.g. “Staff support theimplementation of policies that increase healthy eatingopportunities at school.” Similarly, 4 items assessed sup-port for physical activity guidelines by each stakeholdergroup, e.g. “Staff support the implementation of policieswhich increase physical activity for students.” Generalsocial pressure to provide healthier food and beverageitems and increase physical activity at schools wasassessed with two items. All items were measured on a4-point likert scale (strongly agree to strongly disagree).ImplementationThe extent of implementation of the food and beverageguidelines in a variety of locations (snack bar, vendingmachine, cafeteria, fundraising activities, and schoolevents) was assessed in 2011–12. For each location, prin-cipals reported the percentage of guideline implementa-tion: 0%, 25%, 50%, 75%, 90%, and 100%. The samequestion was asked about the extent of implementationof the DPA guidelines for each grade separately. A re-sponse of 100% was considered to be full implementa-tion, 25% and 90% was considered to be in process, and0% was considered to be no implementation.Socio-demographic variablesSchool size was assessed as a continuous variable usingthe number of students enrolled in each school obtainedfrom the BC Ministry of Education. Community type,the percentage of the population with a high school dip-loma and median household income were obtained fromthe 2006 Canadian census and linked to our school-leveldata using postal codes. Community type was groupedinto three categories based on how the census classifiesgeographical areas: an urban setting that consists ofmetropolitan areas (population ≥ 100,000 and an urbanWatts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 3 of 10http://www.ijbnpa.org/content/11/1/50core ≥ 50,000), a suburban setting (census tract or non-tract agglomeration where urban core ≥10,000), and arural setting (any area that does not meet criteria for anurban or suburban setting).AnalysisMeans, standard deviations and percentages were calcu-lated to describe our sample characteristics. Multilevelmixed effects linear and logistic regression was used tomodel changes over time in availability of food and bev-erages, minutes per week of PE, delivery method of PE,and school stakeholder support for nutrition and PE pol-icies. Mixed effects modeling was used to account forthe clustering of schools within districts and to addressthe unbalanced nature of our dataset (i.e., schools thatcontributed data at one or both time points were in-cluded in the analysis). This procedure was selected as itis slightly more powerful than examining only schoolsthat provided data in both 2007–08 and 2011–12 (cohortsample).Models examining changes in the school food environ-ment were conducted separately for elementary andmiddle/high schools; therefore, mixed grade schoolswere excluded from the analysis (n = 25). Separate ana-lyses were appropriate because Canadian elementary andmiddle/high schools differ substantially with respect totheir food environment e.g., most elementary schools donot have vending machines or cafeterias. Separatemodels were also run for each food and beverage item.If less than 10% of schools reported availability of a par-ticular food/beverage the model was not run. To exam-ine changes in PE minutes per week and deliverymethod, separate models were run for grade 6, 8 and 10students. All models controlled for school enrollmentand community type, education and income. Unadjustedand adjusted odds ratios and 95% confidence intervalswere reported for logistic models, while unstandardizedand standardized beta coefficients and p-values were re-ported for linear models. A p-value of less than 0.05 wasconsidered statistically significant. Analyses were con-ducted using the XTMIXED and XTMELOGIT com-mands in STATA v.11 (StataCorp, Texas, US).In sub-analyses, we examined whether the cohortschools differed significantly from schools that partici-pated in 2007–08 only. As compared to cohort schools,those that did not agree to participate again in 2011–12had similar demographic and socio-economic character-istics, but a smaller proportion of middle/high schoolsoffered French fries (32.4% vs. 54%, p < .001). No otherdifferences were identified. We also conducted ana-lyses in cohort schools only and found that the esti-mates (e.g., means and percentages) remained unchanged(data not shown). Furthermore, the stability of these esti-mates was confirmed by testing interactions between timeand sample membership (i.e., cohort vs. participated in2007–08 or 2011–12 only) and no interactions were sig-nificant (data not shown) providing further support tocombine the two groups in our mixed effects analyses.ResultsImplementationAccording to middle/high school principals in 2011–12,66% reported full implementation of guidelines for vend-ing machines, followed by 45%, 36%, 10% and 8% forsnack bars, cafeterias, fundraising activities and specialevents, respectively. Among elementary schools, 22%and 15% reported full implementation of the guidelinesfor fundraising activities and special events, respectively.The majority of elementary schools did not have a vend-ing machine (78%), cafeteria (95%) or snack bar (88%);therefore, implementation of these guidelines is not pre-sented. For grade 6 students, 65.2% of schools reportedfull implementation of the DPA guidelines followed by56% and 51% for grade 8 and 10 students, respectively.School nutrition environmentChanges in school availability of specific food and bever-ages are described in Table 1. Few elementary schools(<10%) reported availability of sugar-sweetened bever-ages, baked goods, French fries, chocolate & candy, orsalty snacks (low-fat and regular) at either time point,thus changes in these items were not modeled. Resultsfrom mixed effects modeling reveal that elementaryschools had higher odds of having fruit (OR = 2.13, 95%CI = 1.36-3.35) and vegetables (OR = 2.87, 95% CI = 1.51-5.44) and lower odds of having 100% fruit juice (OR = 0.40,95% CI = 0.25-0.65) available in the 2011–12 school year(Table 2). There was no change in the availability of pizza,hamburgers & hotdogs or low-fat baked goods in elemen-tary schools. Middle/high schools had lower odds of havingsugar-sweetened beverages (OR = 0.51, 95% CI = 0.30-0.88), regular baked goods (OR = 0.28, 95% CI = 0.15-0.52),chocolates & candy (OR = 0.06, 95% CI = 0.01-0.36), regu-lar salty snacks (OR = 0.11, 95% CI = 0.05-0.25) and Frenchfries (OR = 0.30, 95% CI = 0.11-0.80) available in the 2011–12 school year. No other food or beverage products signifi-cantly changed over time. In the 2011–12 school year, afterthe guidelines were expected to be implemented, mostprincipals reported that their school was serving pizza,hamburgers and hotdogs with whole wheat crust or buns:59%, 72% and 69%, respectively, among elementary schoolsand 56%, 70% and 62%, respectively, among middle/highschools.Physical educationChanges to the duration and delivery method of PE aredescribed by grade in Table 1. After adjusting for schooland community variables, schools had higher odds ofWatts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 4 of 10http://www.ijbnpa.org/content/11/1/50meeting the recommended amount of 150 minutesper week of PE for grade 6 students (OR = 2.01, 95%CI = 1.00-4.3) and provided more minutes of PE to grade 8(b = 17.72, p < .001) and grade 10 students (b = 11.17,p = 0.01) in 2012 (Table 3). Schools had higher odds ofproviding PE linearly to grade 8 students and in a semes-ter format for grade 10 students in 2011–12 as comparedto 2007–08.School community supportLevels of stakeholder support are presented in Table 1.After controlling for school and community variables,principal reported staff and parent support for healthyeating and physical activity policies significantly in-creased in elementary and middle/high schools (Table 4).Student support for healthy eating policies increasedwhile principal support decreased among elementaryschools, with no changes among middle/high schools.Student support for physical activity policies decreasedamong elementary schools but increased among middle/high schools as did social pressure to provide morephysical activity at school. Principal support for physicalactivity policies did not change over time.DiscussionThis study is one of very few that examined the impactof both nutrition and physical activity school guidelineson the school environment. Results demonstrate thatafter BC schools were expected to implement the foodand beverage guidelines and daily physical activity re-quirements, schools decreased their availability of lesshealthful food and beverages and increased the numberof minutes of PE offered per week, based on principalreport. These changes are encouraging and similar tothe policy impacts found in other jurisdiction [18-21].Further evaluation to determine if these policies will im-pact student behaviors is warranted.Change in school nutrition environmentThe FBSS guidelines resulted in significant changes tothe school food environment but impacted elementaryand middle/high schools differently. Differences may bepartly explained by the amount of food and beveragesavailable at school to start with [4,20]. Overall, middle/high schools decreased the availability of less healthfulfood and beverages whereas elementary schools de-creased the availability of less healthful beverages andsignificantly increased the availability of fruits and vege-tables at school. The increase in fruits and vegetableswas somewhat unexpected since the guidelines did notmandate schools to offer more healthy options but maybe the result of the government scaling up provincialprograms that targeted elementary schools over this timeperiod such as the fruit and vegetable program that in-cluded bi-weekly delivery, raising awareness of local pro-duce, ‘tasting’ activities, and materials for teachers, and awhole school physical activity and healthy eating initia-tive that provided technical support and resources toTable 1 Description of the school nutrition and physicaleducation environment of schools, British Columbia, CanadaElementarySchoolsMiddle/HighSchools2007–08(n = 384)2011–12(n = 351)2007–08(n = 118)2011–12(n = 125)Mean (SD)/%Availability of Food and BeveragesSugar-sweetenedBeverages5.5% 5.7% 62.7% 44.8%French Fries 0 0.3% 41.5% 25.6%Chocolate and Candy 0 0 37.3% 10.4%Regular Salty Snacks 0.3% 1.14% 40.7% 7.2%Regular Baked Goods 2.9% 4.3% 53.4% 26.4%Low-fat Salty Snacks 6.3% 8.0% 78.8% 75.2%Low-fat Baked Goods 10.4% 13.7% 70.3% 74.4%Pizza, Hotdogs,Hamburgers13.3% 18.0% 63.6% 68.0%Fruit 28.9% 39.3% 74.6% 78.4%100% Fruit Juice 49.0% 34.5% 95.8% 92.8%Vegetables 9.4% 17.4% 69.5% 66.4%Physical EducationGrade 6 - -< 150 min PE/week 65.9% 51.9%≥150 min PE/week 34.1% 48.1%Grade 8 - -PE minutes/week 180.1 (30.4) 199.1 (47.1)Linear vs. Semester - - 67.0% 79.0%Grade 10 - -PE minutes/week 184.0 (23.7) 194.0 (38.2)Linear vs. Semester - - 50.5% 39.8%Support for Nutrition PoliciesGeneral Social pressure 2.73 (0.70) 2.71 (0.66) 2.74 (0.68) 2.62 (0.66)Principal Support 3.49 (0.52) 3.34 (0.51) 3.39 (0.54) 3.29 (0.49)Staff Support 2.77 (0.58) 3.16 (0.44) 2.67 (0.66) 3.06 (0.45)Student Support 2.57 (0.61) 2.70 (0.63) 2.42 (0.74) 2.44 (0.65)Parent Support 2.79 (0.63) 2.92 (0.53) 2.77 (0.78) 3.0 (0.59)Support for Physical Education PoliciesGeneral Social Pressure 2.43 (0.69) 2.64 (0.68) 2.18 (0.69) 2.33 (0.58)Principal Support 2.57 (0.66) 2.70 (0.65) 2.57 (0.66) 2.70 (0.65)Staff Support 2.89 (0.60) 3.15 (0.48) 2.29 (0.67) 2.73 (0.60)Student Support 3.34 (0.57) 3.21 (0.48) 2.50 (0.69) 2.66 (0.36)Parent Support 2.40 (0.63) 3.11 (0.47) 2.14 (0.69) 2.79 (0.52)Watts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 5 of 10http://www.ijbnpa.org/content/11/1/50teachers that were attempting to implement classroomhealthy eating practices [33].Overall, nutritional environment changes in elemen-tary and middle/high schools were all in the expecteddirection. With the exception of the availability of pizza,hamburgers and hotdogs and availability of 100% fruitjuices (only in middle/high schools), the guidelines seemto have targeted the appropriate food and beverageitems. It is not surprising that the availability of pizza,hamburgers and hotdogs did not change over time be-cause the guidelines allowed reformulation of these prod-ucts as opposed to restriction. Reformulations focused onimproving grains and reducing fat, sodium and additivesrather than increasing vegetables. Indeed, we found thatafter implementation of the guidelines a large proportionof schools (>50%) were serving these items with wholegrains. If children continue to eat only these reformu-lations, the guidelines might fall short in increasingchildren’s consumption of vegetables at lunch time.Furthermore, elementary schools significantly decreasedthe availability of 100% fruit juice while middle and highschools significantly decreased the availability of sugar-sweetened beverages but not 100% fruit juices where avail-ability remained high (94%). Although 100% fruit juicewas not targeted by the guidelines, it may have been usedto replace sugar-sweetened beverages in middle/highschool vending machines. When consumed in appropriateportions, 100% fruit juice is not problematic; [34] however,Table 2 Changes in availability after implementation of school food and beverage guidelines, British Columbia,Canada (2007/08–2011/12)Elementary Schools Middle/High SchoolsUnadjusted models Adjusted models1 Unadjusted models Adjusted models1N OR (95% CI) N OR (95% CI) N OR (95% CI) N OR (95% CI)Sugar-sweetened Beverages - - 238 0.52 (0.31-0.87) 236 0.51 (0.30-0.88)French Fries - - 241 0.26(0.09-0.76) 238 0.30 (0.11-0.80)Chocolate and Candy - - 240 0.07 (0.01-0.40) 238 0.06 (0.01-0.36)Regular Salty Snacks - - 239 0.10 (0.04-0.24) 237 0.11 (0.05-0.25)Regular Baked Goods - - 240 0.26 (0.14-0.49) 238 0.28 (0.15-0.52)Low-fat Salty Snacks - - 239 0.87 (0.41-1.88) 237 1.03 (0.53-2.01)Low-fat Baked Goods 715 1.51 (0.79-2.89) 707 1.54 (0.81-2.91) 240 1.51 (0.79-2.89) 237 1.48 (0.79-2.79)Pizza, Hotdogs, Hamburgers 712 1.70 (0.96-2.89) 704 1.65 (0.95-2.88) 239 1.46(0.76-2.8) 236 1.47 (0.80-2.71)Fruit 715 1.98 (1.25-3.15) 707 2.13 (1.36-3.35) 239 1.71 (0.75-3.91) 237 1.67 (0.79-3.53)100% Fruit Juice 718 0.40 (0.25-0.65) 710 0.40 (0.25-0.65) 241 0.58 (0.10-3.44) 238 0.64 (0.12-3.34)Vegetables 716 2.84 (1.49-5.42) 708 2.87 (1.51-5.44) 240 0.96 (0.41-2.25) 238 1.02 (0.48-2.18)1Mixed effects logistic regression models were adjusted for neighborhood-level median household income, percent with post-sec education, school size, andschool location.OR, odds ratio; CI, confidence interval.Bolded odds ratios are statistically significant at p < 0.05.Table 3 Changes in physical education after implementation of the physical activity guidelines, British Columbia,Canada (2007/08–2011/12)Unadjusted models Adjusted modelsaN Odds Ratio (95% CI) b (p-value) N Odds Ratio (95% CI) b (p-value)Grade 6 PE (≥150 min/week)b 401 2.10 (0.97-4.44) – 388 2.01 (1.00-4.30) –Grade 8 PE min/weekc 227 – 18.66 (<.001) 218 – 17.72 (<.001)Delivery (Linear)d 231 3.77 (1.10-12.92) – 222 3.45 (1.15-10.28) –Grade 10 PE min/weekb 199 – 9.12 (0.04) 192 – 11.17 (0.01)Delivery (Linear)d 204 0.51 (0.19-1.36) – 197 0.42 (0.15-1.19) –aModels were adjusted for neighborhood-level median household income, percent with post-sec education, school size, and school location.bMixed effect logistic regression examining the odds of offering greater than or equal to 150 minutes of PE per week versus offering less than 150 minutes perweek, in 2011–12 as compared to 2007–08.cMixed effect linear regression, mean increase in minutes of PE per week between 2007–08 and 2011–12.dMixed effect logistic regression examining the odds of offering PE as a linear course versus a semester course in 2011–12 as compared to 2007–08.CI, confidence interval; b, unstandardized regression coefficient; Bolded estimates are statistically significant at p < 0.05.Watts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 6 of 10http://www.ijbnpa.org/content/11/1/50large servings of 100% fruit juice have been suggested as apotential contributor to children’s positive energy balance[35,36]. Continued monitoring of such policies is essentialto ensure that consumption of sugar-sweetened beveragesis not replaced by consumption of inappropriate portionsof 100% fruit juice.Many schools reported that they continue to strugglewith making changes to their food environment. Imple-mentation was particularly low for fundraising activitiesand special events among both elementary and middle/high schools as well as for cafeterias among middle/highschools. As we discovered from in-depth interviews withschool principals and teachers in 2010–11, fundraisingactivities and special events may be particularly challen-ging areas for schools to make changes since access tohealthier alternatives are lacking and there is a potentialfor lost revenue [26]. In addition, school informants re-ported that perceived value, compatibility with schoolmandate/teaching philosophy, observable positive im-pacts, and availability of resources promoted implemen-tation while the complexity of guidelines impededimplementation. Previous studies have also reported thatschools experience a variety of barriers to implementa-tion including funding, competing priorities and supportfrom stakeholders [27]. Furthermore, a Canadian studyidentified lack of support, complexity of guidelines, anda top-down approach as barriers to implementation [37].A key area of future research needs to be in improvingimplementation as gaps in implementation likely resultin reduced policy effectiveness.Previous studies have also reported favorable changesto the school food environment after implementation ofstate or federal policies/guidelines [19,21,38]. A cross-sectional examination of the strength of state nutritionpolicies found that elementary and middle schools withstate policies restricting junk food had lower availabilityof junk food in vending machines and school stores,with no change in high schools [19]. This result differsfrom the current study, where we found declines in lesshealthful food among middle/high schools but not elem-entary schools. In another study, records of all foodserved for lunch were collected for the years before andafter implementation of the Texas nutrition policy andrevealed that fewer fried vegetables (French fries) wereserved for both elementary and high schools, but nochange was observed for regular vegetables, fruit or milk[38]. Using a similar design as the current study, com-parison before and after the implementation of Maine’sstate-wide nutrition policy banning “foods of minimalnutritional value” found that the availability of soda, butnot other junk foods, declined in high schools [21]. Incontrast, we observed declines in various less healthfulfood products including junks food, along with declinesin sugar-sweetened beverages. Despite the encouragingchanges within the BC school food environment, manyschools continued to serve refined grains and other lesshealthful food and beverages.Change in school physical activity environmentAfter the DPA policy was put into place, schools in-creased minutes of PE per week for grade 6, 8, and 10students. Unlike most US state policies, the BC guide-lines were not specific about increasing PE time but in-stead allowed schools choice in how to increase physicalactivity. In elementary schools, schools could meet theguidelines by implementing the Action Schools! BC ini-tiative that was supported by the province. A key strat-egy of Action Schools! BC was to increase physicalactivity breaks in the classroom [39,40]. While the DPAguidelines did not directly target PE time, we found thatmany schools opted to increase PE time to meet the pro-vincial guidelines. This finding is corroborated by resultsfrom our qualitative study that examined (among others)strategies schools used to implement the DPA guidelines[26]. Our data did not allow for comparison of the im-pact of the two approaches in achieving the guideline. Inthe province of Ontario, where a similar DPA policy wasmandated in 2005, a cross-sectional study using accel-erometry reported that 5-years into implementation ofthe policy, the majority of students were not active onevery school day and no child met sustained activity for20 minutes at one time, suggesting that schools were notTable 4 Changes in stakeholder support afterimplementation of school guidelines, British Columbia,Canada (2007/08–2011/12)a,bElementary Schools Middle/High SchoolsN b p-value N b p-valueSchool NutritionSocial Pressure 703 -0.30 .55 231 -0.10 .20Principal Support 712 -0.14 <.001 235 -0.98 .14Staff Support 704 0.40 <.001 231 0.39 <.001Student Support 575 0.15 .004 226 0.02 .82Parent Support 710 0.11 .02 233 0.24 .003Physical EducationSocial Pressure 704 0.20 <.001 230 0.18 .02Principal Support 702 -0.05 .27 222 0.14 .06Staff Support 699 0.26 <.001 222 0.43 <.001Student Support 709 -0.11 .003 222 0.19 .02Parent Support 705 0.69 <.001 238 0.07 <.001aSeparate models were run for each support variable.bMixed effects linear models were adjusted for neighborhood-level medianhousehold income, percent with post-sec education, school size, andschool location.b, unstandardized regression coefficient.Bolded estimates are statistically significant at p < 0.05.Watts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 7 of 10http://www.ijbnpa.org/content/11/1/50meeting the guidelines [41]. Further investigation is re-quired to investigate the relative value of a DPA guide-line versus a daily PE guideline.In the current study, schools also changed their deliv-ery method of PE from semester to linear for grade 8students, while the opposite occurred for grade 10 stu-dents. This is a puzzling finding. We had hypothesizedthat schools might move towards a linear system to de-liver PE (shorter bouts spread out over the whole year);however, this finding aligns with our qualitative inter-views that suggest schools are challenged with fitting ac-tivity into a very busy school schedule [26]. This did notseem to be the case for students in grade 10. Unlike ingrades 6 and 8, PE in grade 10 is a graduation require-ment. Perhaps more grade 10 schools opted to increasephysical activity classes and as a result offered PE on asemester system which is easier to accommodate in theschedule given that all other academic courses are on asemester system.Although the guidelines examined in the current studywere not specific to PE, several US studies have reportedsimilar positive changes to PE time after implementationof PE-specific policies [24,25]. A study of elementaryschools found that schools were more likely to meet therecommended 150 minutes per week of PE once thestate policy was in place [24]. In another study of mid-dle/high schools, minutes of PE per week increased by18 minutes for grade 8 students and 11 minutes forgrade 10 students. Increased minutes of PE time also oc-curred after policy implementation in US high schools[25]. These increases are meaningful as a recent studyfound that students did not compensate by being less ac-tive at home; thus, school PE increased their overallphysical activity levels [42].Change in school community support for healthierguidelinesThe successful changes made by schools in this studyoccurred concurrently with increased support from theschool community for healthier eating and physical ac-tivity. Greater support by school community has previ-ously been identified as key component to successfulimplementation of school policies/guidelines [26,27,43].Increases in staff and parent support were consistentacross school and guideline type suggesting that supportfrom these two groups is important for fostering change.In general, support increased more for physical activitypolicies than healthy eating policies. This may be a con-sequence of the differing implementation context.Changes in DPA are largely the responsibility of theteacher and have no impact on fundraising whilechanges in food policies involve parents and affect fun-draising. In addition, the lowest increase in support forhealthy eating was among middle/high school students,where support was also lowest at baseline. Restrictionson food may be particularly unpopular among this agegroup as they are developing independence and have ac-cess to choices off school property when schools do notprovide them [26,44]. There was no change in policysupport by the principal; however, they also had self-reported the highest level of initial support for bothhealthy eating and physical activity across school types.LimitationsAlthough this study focused on the implementation ofguidelines within the BC context, similar policies are be-ing adopted in other jurisdictions making these findingsrelevant to other settings. This study was limited tomostly principal reports of the school environmentwhich may be influenced by social desirability bias, un-measured characteristics of the respondent, or differ-ences in respondents at each time point. However, ourself-report showed some validity as associations betweenimplementation and school environment were in the ex-pected direction (higher implementation significantly as-sociated with less unhealthy food and beverages andmore PE minutes - data not shown). While we acknow-ledge the limitations of self-report, studies that are ableto utilize objective measures such as food purchasingdata or direct observation of school cafeterias may finddifferent results. Importantly, some changes were madeas to how the questions were asked at each time point;this specifically pertains to the PE questions (see theMethods section). Every effort was made to treat data ina way that enhanced comparability over time but it ispossible that changing the questions influenced the re-sults as principals may have interpreted the question dif-ferently. Our analysis incorporated cross-sectional samplesat each time point which may have contributed to bias inour findings. This impact is likely minimal since our resultsare stable with and without the inclusion of the cross-sectional samples (see Methods section). Furthermore, animportant limitation of natural experiments is that we can-not control for other concurrent school, community orprovincial programs that may contribute to observedchanges in the school environment. As there were provin-cial initiatives targeted at elementary schools during ourevaluation period, the changes observed in elementaryschools may have been attributed to both the enactment ofthe FBSS or DPA guidelines and support provided for theseinitiatives. Finally, we did not examine changes in studentlevel behaviors; however, this will be an important compo-nent of future policy evaluations, particularly in light of evi-dence that suggests increases in PE time may results indecreased forms of other school-based physical activity,such as at recess, [24] and that students may turn to foodand beverages available off school property if they can’t getthem at school [26,44]. Despite these limitations, this studyWatts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 8 of 10http://www.ijbnpa.org/content/11/1/50capitalized on a natural experiment with data collected be-fore and after full implementation of guidelines were ex-pected, providing a rare opportunity to demonstrate policyimpact at the school-level.ConclusionsPositive changes to the school food environment oc-curred after schools were expected to implement theFBSS and DPA guidelines. Fewer middle/high schools of-fered unhealthy food and more elementary schools of-fered healthy food. Simultaneously schools were providingmore minutes of PE to students. Our findings also identi-fied several key areas that might require more attention infuture evaluation. Previous research has linked changes inthe school environment with student’s nutrition and phys-ical activity behaviors and obesity, [1,8,16] thus thechanges observed are encouraging and highlight the rele-vance of policy interventions to enhancing the health en-vironment in schools.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAW conducted the data analysis and contributed to interpreting the resultsand writing and editing the manuscript. LM contributed to conceptualizingthe study, interpreting the results, and writing and editing the manuscript.PJN contributed to conceptualizing the study, interpreting the results, andediting the manuscript. All authors have read and approved the finalmanuscript.AcknowledgmentsThis study was funded by the Canadian Institutes of Health Research (CIHR)Institute of Nutrition, Metabolism and the Institute of Human Development,Child and Youth Health 200905GIR-206392-GIR-CAAA-143786. Establishmentfunds from the Michael Smith Foundation for Health Research were used tocollect some of the data. AWW is funded through a CIHR Doctoral ResearchAward in partnership with the Danone Institute of Canada and through aCIHR fellowship in population interventions for chronic disease prevention inpartnership with the Heart and Stroke Foundation of Canada. LCM wasfunded through salary support provided by the Child and Family ResearchInstitute.Author details1School of Population and Public Health, University of British Columbia,F508-4480 Oak Street, Vancouver, British Columbia V6H 3V4, Canada. 2Schoolof Exercise Science, Physical and Health Education, University of Victoria, POBox 3015 STN CSC, Victoria, British Columbia V8W 3P1, Canada. 3Departmentof Pediatrics, University of British Columbia, F508-4480 Oak Street, Vancouver,BC V6H 3V4, Canada.Received: 10 October 2013 Accepted: 1 April 2014Published: 14 April 2014References1. Fox MK, Dodd AH, Wilson A, Gleason PM: Association between schoolfood environment and practices and body mass index of US publicschool children. J Am Diet Assoc 2009, 109:S108–S117.2. Rideout K, Levy-Milne R, Martin C, Ostry AS: Food sales outlets, food availability,and the extent of nutrition policy implementation in schools in BritishColumbia. Can J Public Health 2007, 98:246–250.3. 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Stone MR, Faulkner GE, Zeglen-Hunt L, Bonne JC: The Daily PhysicalActivity (DPA) policy in Ontario: is it working? An examination usingaccelerometry-measured physical activity data. Can J Public Health2012, 103:170–174.42. Long MW, Sobol AM, Cradock AL, Subramanian SV, Blendon RJ, GortmakerSL: School-day and overall physical activity among youth. Am J Prev Med2013, 45:150–157.43. MacLellan D, Holland A, Taylor J, McKenna M, Hernandez K: Implementingschool nutrition policy: student and parent perspectives. Can J Diet PractRes 2010, 71:172–177.44. Poti JM, Popkin BM: Trends in energy intake among US children byeating location and food source, 1977–2006. J Am Diet Assoc 2011,111:1156–1164.doi:10.1186/1479-5868-11-50Cite this article as: Watts et al.: Changes to the school food and physicalactivity environment after guideline implementation in BritishColumbia, Canada. International Journal of Behavioral Nutrition and PhysicalActivity 2014 11:50.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/submitWatts et al. International Journal of Behavioral Nutrition and Physical Activity 2014, 11:50 Page 10 of 10http://www.ijbnpa.org/content/11/1/50

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