PARTICIPATION IN SCHOOL FOOD AND NUTRITION PROGRAMS AND ASSOCIATIONS WITH DIETARY PSYCHOSOCIAL AND BEHAVIOURAL OUTCOMES AMONG VANCOUVER STUDENTS IN GRADES 6-8 by Teya Anne-Margaret Stephens A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Human Nutrition) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) June 2014 © Teya Anne-Margaret Stephens, 2014 ii Abstract Background: Diet-related health conditions, including obesity and type 2 diabetes, are a growing concern among Canadian youth. In Canada, there is also a rising interest in the impact of dietary choices on environmental sustainability. Several school food and nutrition programs (SFNPs) have been implemented to improve dietary quality and environmental sustainability, including gardening and food preparation programs. However, limited research has examined the links between participation in SFNPs and dietary psychosocial and behavioural outcomes. Purpose: To examine healthy and environmentally sustainable dietary attitudes, expectations, choices, and practices, and current participation rates in SFNPs among Vancouver students in grades 6-8, and to evaluate whether participation in SFNPs is associated with these outcomes. Methods: A cross-sectional study was conducted in 26 schools in Vancouver from March-June, 2012 (n=937 students). Schools were selected using non-probability sampling. A web-based survey, including a food frequency questionnaire, measured student demographic characteristics, participation in SFNPs, and dietary psychosocial and behavioural outcomes. Rao-Scott corrected chi-square tests were applied to assess associations between SFNPs and outcomes (p<0.05). Results: Less than 50% of students reported participating in SFNP activities, with the exception of recycling (51.2%). Greater than 50% reported the importance of health and environmental sustainability when making food purchases, and agreement that food choices impact health or the environment. However, < 50% of students reported daily intake of most healthy and weekly intake of most environmentally sustainable dietary choices. Approximately 1/3 of students reported weekly purchasing from convenience food establishments. Participation in activities specific to learning about food or nutrition was greater among females, and secondary school students reported greater participation in food-specific activities. Activities specific to learning about food or nutrition demonstrated expected associations with outcomes. Most associations between hands-on food-related activities were in the unanticipated direction. Conclusions: Findings demonstrate marginal participation in SFNPs and intake of healthy and environmentally sustainable dietary choices among Vancouver students. Results also reveal the possible role of activities specific to learning about food or nutrition in promoting healthy and environmentally sustainable diet-related outcomes. Further research on SFNPs to inform curriculum changes could improve student dietary behavioural outcomes, student health, and environmental sustainability. iii Preface Contributions and collaborations involved in the research study identification and design of the research program The author was not involved in the initial identification and design of the research program from which the specific thesis research emerged. Questionnaire development described in Chapter 2 was based on collaborative work conducted in the UBC Food Nutrition and Health Building primarily by the following research study members: Dr. Jennifer Black (Graduate Supervisor), Dr. Gwen Chapman (Graduate Supervisory Committee member), Naseam Ahmadi (Graduate student) and Stephanie Shulhan (Graduate student). Author was involved in the questionnaire development process, and was assigned the main responsibility for developing the food frequency questionnaire and the School Food and Nutrition Program (SFNP) question set in conjunction with Dr. Jennifer Black, with feedback from other study members. The author also assisted with questionnaire revisions. Lastly, the author was assigned responsibility for the development of the protocol implemented for both recruitment of school classes and questionnaire administration, with integration of feedback primarily from Dr. Jennifer Black and Naseam Ahmadi. Performance of various parts of the research The author was responsible for contacting approximately half of the schools recruited for the study and providing the appropriate parent/guardian passive consent forms. In addition, the author also lead approximately half of the survey sessions at each school, typically with the assistance of a research team member or graduate student research assistant, including TEGS research assistants. Survey sessions included several procedural steps, including providing detailed verbal instructions, iv recording class student numbers, distributing and collecting forms, writing field notes, and assisting students as required throughout the survey. Following conducted survey sessions, the author also transcribed class numbers, field notes, and student contact information into an electronic spreadsheet, as well as organized all forms appropriately for filed storage. Analysis of the research data The generation of variables and approach to data analysis as described in Chapter 2 was a collaborative effort among research team members, which included contributions from Dr. Cayley Velazquez, Naseam Ahmadi, as well as guidance and feedback from Dr. Jennifer Black and Dr. Jean-Michel Billette. Student characteristic variables were mainly developed by Dr. Cayley Velazquez and Naseam Ahmadi. The author’s contribution to the collaborative work was primarily in assisting with the approach applied towards combining food frequency questionnaire items into dietary choice categories and towards dichotomizing dietary choice categories into a frequency of daily (once a day or more) versus less than daily. The variables that were generated by the author (with feedback and guidance primarily from Dr. Black and Dr. Velazquez) included: School Food and Nutrition Program (SFNP) variables, dietary related attitudes and expectations, environmentally sustainable dietary choices, and the majority of food practices. The University of British Columbia Office of Research Services Behavioural Research Ethics Board awarded a certificate of approval of minimal risk to this study from June 21, 2011 to June 21, 2012. Certificate #: H11-01369 v Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iii Table of Contents ...........................................................................................................................v List of Tables ............................................................................................................................... xii List of Figures ............................................................................................................................. xiv Acknowledgements ......................................................................................................................xv Dedication ................................................................................................................................... xvi Chapter 1: Introduction ...............................................................................................................1 1.1 Role of School Food and Nutrition Programs ...................................................................... 1 1.2 An Overview of Dietary Attitudes, Expectations, Choices, and Food Practices, and Participation in School Food and Nutrition Programs among Children and Adolescents ............... 4 1.2.1 Healthy Dietary Choices .................................................................................................. 5 1.2.2 Environmentally Sustainable Dietary Choices ................................................................ 6 1.2.3 Both Healthy and Environmentally Sustainable Dietary Choices ................................. 11 1.2.4 Healthy and Environmentally Sustainable Food Practices ............................................ 14 1.2.5 Summary of Healthy and Environmentally Sustainable Dietary Choice and Food Practice Recommendations ........................................................................................................ 16 1.2.6 Dietary Attitudes and Expectations ................................................................................ 17 1.2.7 Theoretical Framework to Describe Associations between Participation in SFNPs and Dietary Psychosocial and Behavioural Outcomes ..................................................................... 19 1.2.8 Overview of School Food and Nutrition Programs Available in Vancouver ................ 20 vi 1.2.8.1 Food Preparation Activities ................................................................................... 22 1.2.8.2 Choosing or Tasting Healthy Foods Activities ...................................................... 23 1.2.8.3 Learning about Canada’s Food Guide ................................................................... 24 1.2.8.4 Learning about Foods Grown in British Columbia ................................................ 25 1.2.8.5 Gardening Activities .............................................................................................. 26 1.2.8.6 Composting Activities............................................................................................ 27 1.2.8.7 Recycling Activities ............................................................................................... 28 1.3 Literature on School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Psychosocial and Behavioural Outcomes ...................................................... 28 1.3.1 Participation in School Food and Nutrition Programs and Differences by Gender and School Type ............................................................................................................................... 30 1.3.2 Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ............ 34 1.3.3 Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days ............................................................................................................................... 37 1.3.4 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ..................................... 40 1.3.5 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days .......... 45 1.3.6 Literature on Specific SFNPs Implemented in Vancouver and North America ............ 50 1.4 Summary of Current Gaps in the Literature Investigating School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Psychosocial and Behavioural Outcomes ....................................................................................................................................... 52 vii 1.4.1 Participation in School Food and Nutrition Programs and Differences by Gender and School Type ............................................................................................................................... 53 1.4.2 Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ............ 53 1.4.3 Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days ............................................................................................................................... 54 1.4.4 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ..................................... 54 1.4.5 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days .......... 55 1.5 Study Purpose and Objectives............................................................................................ 55 Chapter 2: Research Methods ...................................................................................................58 2.1 Study Design ...................................................................................................................... 58 2.2 Questionnaire Development ............................................................................................... 58 2.2.1 Participation in School Food and Nutrition Programs ................................................... 60 2.2.2 Dietary Attitudes ............................................................................................................ 63 2.2.3 Dietary Expectations ...................................................................................................... 65 2.2.4 Dietary Choices .............................................................................................................. 66 2.2.5 Food Practices ................................................................................................................ 71 2.3 Data Collection .................................................................................................................. 73 2.3.1 Participants ..................................................................................................................... 74 2.3.2 Sampling and Recruitment ............................................................................................. 75 2.3.3 Questionnaire Administration ........................................................................................ 77 2.4 Analytic Sample ................................................................................................................. 78 viii 2.5 Final Measures and Coding................................................................................................ 81 2.5.1 Participant Characteristics .............................................................................................. 81 2.5.2 School Food and Nutrition Program Activities.............................................................. 81 2.5.3 SFNP Clubs and Teaching Cafeterias ............................................................................ 84 2.5.4 Dietary Psychosocial and Behavioural Outcome Variables .......................................... 84 2.5.4.1 Dietary Attitudes .................................................................................................... 88 2.5.4.2 Dietary Expectations .............................................................................................. 89 2.5.4.3 Dietary Choices ...................................................................................................... 90 2.5.4.4 Food Practices ........................................................................................................ 94 2.5.5 Missing and Inconsistent Responses to Variables ......................................................... 97 2.6 Data Analysis ..................................................................................................................... 98 2.6.1 Statistical Tests .............................................................................................................. 98 2.6.1.1 Variables Included in Bivariate Analyses between SFNPs and Outcomes ........... 99 2.6.1.2 Categorization of SFNPs and Expected Associations with Dietary Psychosocial and Behavioural Outcomes .................................................................................................. 101 Chapter 3: Results.....................................................................................................................105 3.1 Student Characteristics ..................................................................................................... 105 3.2 Participation in School Food and Nutrition Programs ..................................................... 107 3.2.1 Student-Level Participation in Individual SFNP Activities ......................................... 107 3.2.2 Student-Level Participation in SFNP Activity Categories ........................................... 109 3.2.3 School-Level Participation in SFNP Activity Categories ............................................ 110 3.2.4 Participation in SFNP Activity Categories by Gender and School Type .................... 112 3.3 Healthy and Environmentally Sustainable Dietary Attitudes .......................................... 114 ix 3.4 Healthy and Environmentally Sustainable Dietary Expectations .................................... 117 3.5 Healthy and Environmentally Sustainable Dietary Choices on School Days .................. 118 3.6 Healthy and Environmentally Sustainable Food Practices on School Days .................... 120 3.7 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ....................................... 123 3.8 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days ............ 137 3.9 Summary of Key Results ................................................................................................. 155 3.9.1 Participation in School Food and Nutrition Programs ................................................. 155 3.9.2 Healthy and Environmentally Sustainable Dietary Attitudes and Expectations .......... 156 3.9.3 Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days ............................................................................................................................. 156 3.9.4 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ................................... 157 3.9.5 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days ........ 160 Chapter 4: Discussion ...............................................................................................................162 4.1 Participation in School Food and Nutrition Programs ..................................................... 162 4.1.1 Student-Level Participation in Individual and Categories of SFNP Activities ............ 162 4.1.2 School-Level Participation in SFNP Activity Categories ............................................ 167 4.1.3 Differences in Participation in SFNP Activities by Gender and School Type ............ 169 4.2 Healthy and Environmentally Sustainable Dietary Attitudes .......................................... 173 4.3 Healthy and Environmentally Sustainable Dietary Expectations .................................... 178 x 4.4 Healthy and Environmentally Sustainable Dietary Choices on School Days .................. 179 4.5 Healthy and Environmentally Sustainable Food Practices on School Days .................... 184 4.6 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations ....................................... 187 4.7 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days ............ 195 4.8 Overall Associations between SFNP Activities and Dietary Psychosocial and Behavioural Outcomes ..................................................................................................................................... 204 4.9 Limitations, Considerations, and Strengths ..................................................................... 205 4.9.1 Limitations ................................................................................................................... 205 4.9.2 Considerations in the Interpretation of Results ............................................................ 218 4.9.3 Strengths....................................................................................................................... 222 Chapter 5: Conclusions ............................................................................................................225 5.1 Contribution and Significance of the Research ................................................................ 225 5.2 Applications of the Research Findings ............................................................................ 226 5.3 Future Research Directions .............................................................................................. 231 5.3.1 Questionnaire Development ......................................................................................... 232 5.3.2 Evaluation of Participation in School Food and Nutrition Programs .......................... 232 5.3.3 Assessment of Dietary Attitudes and Expectations ..................................................... 233 5.3.4 Assessment of Dietary Choices and Food Practices .................................................... 234 5.3.5 Evaluation of Associations between Participation in SFNPs and Dietary Psychosocial and Behavioural Outcomes ...................................................................................................... 235 5.3.5.1 Research Design and Analysis ............................................................................. 236 xi 5.3.5.2 Details of Activities ............................................................................................. 237 5.3.5.3 Control for Factors Associated with Outcomes and SFNPs ................................ 238 5.3.5.4 Factors Relevant to Dietary Behavioural Outcomes and to the Study Population .............................................................................................................................. 239 5.3.5.5 Establish Significance of Impact of Results of SFNP Outcome Measures.......... 240 5.3.5.6 Evaluate Long-term Effects ................................................................................. 241 5.3.5.7 Future Categories of SFNPs to Investigate .......................................................... 242 5.4 Overall Conclusions ......................................................................................................... 252 References ...................................................................................................................................256 Appendices ..................................................................................................................................274 Appendix A - Study survey .......................................................................................................... 274 Appendix B - Survey session field notes form ............................................................................ 312 Appendix C - Description of removal of participants for final sample ....................................... 314 Appendix D - Individual dietary choice and food practice items combined in creating dietary choice and food practice categories applied in bivariate analyses ............................................... 316 Appendix E - Graphs of participation rates (%) in activity categories by school (n=26) ............ 318 Appendix F - Participation in individual SFNP activities (none and outside of school) ............. 322 Appendix G - Participation in SFNP activity categories (none and outside of school) ............... 324 xii List of Tables Table 2-1 – SFNP individual activities combined in creating final activity categories ..................... 83 Table 2-2 – School food and nutrition program variables ................................................................. 84 Table 2-3 – Dietary psychosocial and behavioural outcome variables .............................................. 85 Table 2-4 – Dietary psychosocial and behavioural outcomes included in bivariate analyses with SFNP activity categories and expected associations with dietary psychosocial and behavioural outcomes .......................................................................................................................................... 104 Table 3-1 – Student characteristics .................................................................................................. 106 Table 3-2 – Student-level participation in individual school food and nutrition program (SFNP) activities (n=937) ............................................................................................................................. 108 Table 3-3 – Student-level participation in school food and nutrition program (SFNP) activity categories (n=937)............................................................................................................................ 110 Table 3-4 – School-level participation in school food and nutrition program (SFNP) activity categories (n=26) (five-number summary) ...................................................................................... 111 Table 3-5 – Student-level participation in school food and nutrition program (SFNP) activity categories by gender and by school type (n=937)............................................................................ 113 Table 3-6 – Healthy and environmentally sustainable dietary attitudes among students (n=937) .. 116 Table 3-7 – Healthy and environmentally sustainable dietary expectations among students (n=937) .......................................................................................................................................................... 117 Table 3-8 – Healthy and environmentally sustainable dietary choices among students on school days (n=937) ............................................................................................................................................. 118 Table 3-9 – Healthy and environmentally sustainable food practices on school days (n=937) ....... 121 xiii Table 3-10 – Associations between participation in activity categories and healthy and environmentally sustainable dietary attitudes (n=937) .................................................................... 124 Table 3-11 – Associations between participation in activity categories and healthy and environmentally sustainable dietary expectations (n=937) .............................................................. 132 Table 3-12 – Associations between participation in activity categories and healthy and less healthy dietary choices on school days (n=937) ........................................................................................... 138 Table 3-13 – Associations between participation in activity categories and environmentally sustainable, less environmentally sustainable, and both less healthy and less environmentally sustainable dietary choices on school days (n=937) ........................................................................ 144 Table 3-14 – Associations between participation in activity categories and healthy and environmentally sustainable food practices on school days (n=937) .............................................. 149 Table 3-15 – Summary of significant associations between activity categories and healthy and environmentally sustainable dietary psychosocial and behavioural outcomes (n=937) .................. 158 xiv List of Figures Figure 2-1 – SFNP individual activity example questions ................................................................ 62 Figure 2-2 – Teaching cafeteria question set for specific jobs performed in the teaching cafeteria.. 63 Figure 2-3 – Dietary attitude example questions ............................................................................... 64 Figure 2-4 – Environmentally sustainable dietary attitude question related to caring ....................... 65 Figure 2-5 – Dietary expectations example questions ....................................................................... 66 Figure 2-6 – Food frequency questionnaire example question set for dietary choice categories (question set for less healthy dietary choice category of Snack foods) ............................................. 68 Figure 2-7 – Food frequency questionnaire example questions from the first set of environmentally sustainable dietary choice item questions .......................................................................................... 69 Figure 2-8 – Food frequency questionnaire example questions from the second set of environmentally sustainable dietary choice item questions ............................................................... 70 Figure 2-9 – Breakfast intake question and response options ............................................................ 72 Figure 2-10 – Lunch intake question and response options ............................................................... 72 Figure 2-11 – Purchasing at convenience food establishments questions ......................................... 72 Figure 2-12 – Selection of final student surveys included in analyses .............................................. 80 xv Acknowledgements Graduate Program Supervisory Committee: • Dr. Jennifer Black (Research Supervisor) • Dr. Gwen Chapman, and Dr. Tim Green (Committee Members) Think&EatGreen@School (TEGS) Project Research Partners, including: • IEAT Research Team (including Dr. Cayley Velazquez, Naseam Ahmadi, and Joshua Edward) • Food Consumption Team (including Dr. Gwen Chapman, and Stephanie Shulhan) • TEGS Principal Investigator (Dr. Alejandro Rojas), and members of the TEGS Coordinating Committee (including Dr. Jennifer Black, Dr. Gwen Chapman, Dr. Cyprien Lomas, Elena Orrego, Will Valley, and Brent Mansfield) • UBC Faculty, graduate research assistants, co-investigators, community partners (including Sarah Carten, RD (Community Nutritionist)) • Vancouver School Board (VSB) and participating schools, teachers, and students Funding by: • Canadian Institutes of Health Research (CIHR) • The UBC Food Nutrition and Health Vitamin Research Fund Think&EatGreen@School Project – Funding by: • The Social Sciences and Humanities Research Council (SSHRC) Community-University Research Alliances (CURA) program xvi Dedication This thesis is dedicated to my research supervisor, Dr. Jennifer Black, who has provided tremendous guidance and encouragement in all stages of the research process. I would also like to profoundly thank my family and friends for their terrific support throughout my degree program. 1 Chapter 1: Introduction Nutrition related health conditions, including obesity and type 2 diabetes, are a growing concern among Canadian children and adolescents. Over the last 30 years, the rate of obesity in Canada among children and youth has increased by approximately three fold (Government of Canada, 2013). Furthermore, there are ≥ 123 newly diagnosed cases of childhood type 2 diabetes in Canada per year (Public Health Agency of Canada, 2011). In addition to the current nutrition related health problems among Canadian youth, there is also a growing concern in Canada and internationally with regard to the environmental implications of current food systems. Existing food systems may have negative impacts on the environment, including effects on climate, water, land, and air (Dewar, Tait, & Wang, 2012). For example, heavy equipment, overgrazing of livestock, and excessive tilling, may lead to damage of soil structure (Harmon & Gerald, 2007). In addition, nitrates contributed through livestock waste and fertilizers pose risk to ecosystems and human health (Harmon & Gerald, 2007). Agriculture also represents a source of significant water resource deterioration (Harmon & Gerald, 2007). Lastly, processes involved in modern food production, manufacturing, distribution, and retailing, rely on energy, and often lead to greenhouse gas emissions, generation of waste, as well as other forms of pollution (Dewar et al., 2012). 1.1 Role of School Food and Nutrition Programs Effective strategies to address the nutrition-related health problems among youth and concerns regarding environmental sustainability are currently needed. Recommendations and initiatives to promote student dietary and psychosocial outcomes related to health and environmental sustainability may help to address nutrition-related health problems among children 2 and adolescents and environmental sustainability. Schools have more recently implemented a variety of school food and nutrition programs (SFNPs) which may have the potential to encourage healthy and environmentally sustainable dietary psychosocial and behavioural outcomes among students. As most children attend school daily, schools have been identified as being in a distinct position to promote and have an impact on healthy eating among children (Jones et al., 2012). The Guidelines for Food and Beverage Sales in B.C. Schools: 2005 (British Columbia Ministry of Education & British Columbia Ministry of Health, 2005), for example, acknowledged the following four points: 1) on a typical school day, approximately one-third of students’ calories are consumed at school (and a significant quantity is purchased on location), 2) proper nutrition is essential to healthy growth and development and can reduce the risk of developing health issues in subsequent years, 3) children who are healthy learn better, and 4) schools can have a direct impact on students’ health (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010). In addition, school-based nutrition interventions have provided a key location where environmental approaches to increase healthy dietary choices among youth can be researched (French & Stables, 2003). Behavior patterns related to health are argued to be learned early in life, are observed to come together in adolescence, and are then seen to continue into adulthood (Perry, Griffin, & Murray, 1985). Furthermore, “[B]ecause adolescents are becoming more autonomous, behaviour patterns acquired during this period are likely to influence long-term behaviours (2)” (Story, Neumark-Sztainer, & French, 2002, p. S40). Adolescent dietary practices may also have an impact on long-term health (Story et al., 2002). It has been stated, that the consolidation of health behaviors early on suggests that interventions should start before sixth grade, prior to when behavioral patterns 3 resist change (Kelder, Perry, Klepp, & Lytle, 1994). Consequently, the implementation of effective school food and nutrition programs targeting youth (including adolescents) may be particularly significant and beneficial in the promotion of healthy and environmentally sustainable dietary choices and food practices among adolescents (and potentially children), which will continue into later years of life. Research to date investigating SFNPs has shown the potential for SFNPs to have a positive impact on dietary psychosocial and behavioural outcomes. Firstly, research on school interventions has shown evidence for attitudes and outcome expectations to act as mediators in changes to dietary behaviours (Cerin, Barnett, & Baranowski, 2009). Furthermore, literature has shown that practical education on food in school settings may be a potential approach towards encouraging interest in healthier eating among children (Jones et al., 2012). Research also indicates that participation in SFNPs may have an impact on student dietary behaviours. In a review of garden-based nutrition-education programs in the United States, authors reported that “Garden-based nutrition-education programs may be an ideal venue to encourage increased intake of vegetables as well as fruits, as they often include the opportunity for youth to plant, harvest, and prepare a vast array of vegetables and some fruits (eg, berries, melons). With multiple exposures to fruits and vegetables through hands-on experiences among their peers, youth may increase their fruit and vegetable intake (6).” (Robinson-O'Brien, Story & Heim, 2009, p. 273-274). Therefore, student involvement in school food and nutrition programs is likely to have a strong influence on the development of student diet-related outcomes, including dietary attitudes and expectations, dietary choices, and food practices. 4 1.2 An Overview of Dietary Attitudes, Expectations, Choices, and Food Practices, and Participation in School Food and Nutrition Programs among Children and Adolescents This chapter will begin by discussing current dietary recommendations to address nutrition-related health concerns among children and adolescents and the environmental sustainability implications of current food systems. Psychosocial factors, which may have an impact on healthy and environmentally sustainable dietary behaviours, such as dietary attitudes and expectations, will also be addressed. In addition, current school food and nutrition programs in Vancouver will be described. Lastly, literature to date in the areas of research investigating participation in school food and nutrition programs, healthy and environmentally sustainable dietary psychosocial and behavioural outcomes among children and adolescents, and associations between participation in school food and nutrition programs and student outcomes related to health or environmental sustainability will be reviewed. The chapter will conclude with the purpose and objectives of this study. As controversy exists in the current recommendations for dietary choices and food practices reflecting healthy and environmentally sustainable choices, owing to the complex nature of how dietary behaviours affect health and the environment over time, this study has applied definitions supported substantively by the current literature, and/or government and health associations, including the American Medical Association, the American Dietetic Association, and Health Canada. These recommendations were used in the evaluation of healthy and environmentally sustainable dietary psychosocial and behavioral outcomes and associations between participation in SFNPs and outcomes related to health or environmental sustainability in this thesis. As will be described in the review of SFNPs available in Vancouver, many of the current healthy and environmentally sustainable dietary recommendations also reflect goal outcome indicators of SFNPs implemented in Vancouver, such as the encouragement of vegetable and fruit intake. However, in 5 order to evaluate whether programs may have an impact on student health or environmental sustainability, healthy and environmentally sustainable outcomes evaluated in this study were based on recommendations described as having a potential impact on health and/or environmental sustainability in scholarly sources, and not on desired outcomes of SFNPs (which may or may not have been based on scholarly evidence showing the potential of program outcomes to influence health and/or environmental sustainability). 1.2.1 Healthy Dietary Choices In order to address current diet-related health concerns among Canadian children and adolescents, government, educational institutions, and organizations, have begun implementing strategies and dietary recommendations to improve healthy dietary choices among youth. Current SFNPs focussing on encouraging healthy dietary behavioural outcomes among students may therefore have the potential to promote student health. Two current Canadian initiatives to support healthy dietary choices among children and adolescents include Eating Well with Canada’s Food Guide (EWCFG) (Health Canada, 2007a) and the Guidelines for Food and Beverage Sales in BC Schools (BC Guidelines) (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010). Eating Well with Canada’s Food Guide (EWCFG) includes recommendations to promote healthy dietary choices and to prevent adverse nutrition-related health conditions, including obesity, type 2 diabetes, cardiovascular disease, some forms of cancer and osteoporosis (Health Canada, 2007b). For example, Canada’s Food Guide recommends drinking water when thirsty and eating foods from all food groups that are low in (or with little or no added) sugar, salt, or fat, such as steamed or baked vegetables and low-fat milk or fortified soy beverages (Health Canada, 2007a). Therefore, energy dense entrees and side dishes, such as hot dogs and french fries (fried potatoes), would 6 typically not meet Canada’s Food Guide food group recommendations. Furthermore, in 2005, as part of a cross-government strategy to support healthier lives in British Columbia, entitled ActNow BC, the Ministries of Health and Education introduced the first Guidelines for Food and Beverage Sales in BC Schools, which reflected BC’s commitment to build healthy learning environments (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010). The guidelines outlined minimum standards of nutrition for food and beverages sold to students, and were expected to support healthy eating in schools (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010). The guidelines pertained to dietary choices sold to students in all school events and settings, including cafeterias, vending machines, school stores, and fundraisers (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010). However, despite efforts to improve dietary intake among children and adolescents, evidence has shown that approximately twenty-five percent of children’s daily calories are acquired from foods and beverages of low nutritional quality, including foods high in fat or sugar, snacks high in sodium, and pop (Heart and Stroke foundation, 2010). In addition, Canada’s Food Guide currently recommends the consumption of 6-8 servings of fruit and vegetables per day for Canadians ages 12-19 overall (Health Canada, 2007a). However, only 43.8% of Canadians ages 12-19 in 2011, and 44.8% of Canadians in this age group in 2012, were consuming vegetables and fruit ≥ 5 times per day (Statistics Canada, 2013). 1.2.2 Environmentally Sustainable Dietary Choices Due to the ongoing concerns regarding negative environmental impacts of contemporary industrialized food systems, several governmental organizations, non-profit community based organizations, and institutions in BC, Canada, and other areas of North America, have initiated 7 strategies and recommendations to improve the environmental sustainability of food systems by addressing some of the main environmental concerns related to food production, distribution, consumption, and disposal. In 2010, for example, the Vancouver School Board developed a Sustainability Framework, with the vision statement to "be the greenest, most sustainable school district in North America.” (Millsip, p. 2). The framework included several goals, including reduction of waste generation and resource consumption, through actions such as recycling and composting (Millsip, 2010, p. 9). Initiatives to promote environmentally sustainable dietary choices have targeted foods and beverages that are locally produced or packaged in environmentally sustainable packaging, and have encouraged alternatives to the consumption of bottled water. Current SFNPs focussing on these dietary recommendations may therefore help to support environmental sustainability. Locally produced foods are often recommended as a dietary choice that supports environmental sustainability. The benefits of local food production in supporting food system sustainability are discussed in Report 8 of the Council on Science and Public Health (A-09): Sustainable Food, published by the American Medical Association (AMA) (2009). The report states that “Locally produced and organic foods are considered part of a healthy, sustainable food system for many reasons. They reduce the use of fuel, decrease the need for packaging and resultant waste disposal, preserve farmland, and/or support a greater diversity of crops” (American Medical Association, 2009, p. 5). Furthermore, the report discusses local food as typically being the most sustainable, requiring fewer resources, being less susceptible to contamination, as well as being less processed and fresher. However, complex questions remain regarding how best to educate the public and change dietary choices and food practices to support sustainability, given the many issues that shape the environmental impact of dietary behaviours. For example, in Canada, the 8 Provincial Health Services Authority (2010) in British Columbia released a summary entitled “A Sustainable Harvest: Weathering the Impact of Climate Change on BC’s Food Supply”, which emphasized that “Unless local food is produced, processed and distributed using sustainable practices, we run the risk of promoting local food that could prove to be more costly to the environment than imported food” (p. 3). The summary described, as an example, that a tomato grown in a local greenhouse that relies on heat from fossil fuels, as opposed to clean sources of energy, may generate greater amounts of greenhouse gas emissions compared to a tomato grown in a field a long distance away (Provincial Health Services Authority, 2010). Nevertheless, in the summary, local foods were recommended as the most sustainable dietary choice (Provincial Health Services Authority, 2010). Several initiatives and reports have been created to support locally produced food in the U.S and in Canada. For example, the Centers for Disease Control and Prevention (CDC) have published the Health and Sustainability Guidelines for Federal Concessions and Vending Operations, which include recommendations to offer food that is organically, locally or sustainably grown, and to label these items appropriately (U.S. Department of Health and Human Services (HHS) & General Services Administration (GSA), 2012). Furthermore, The B.C. Agriculture Plan: Growing a Healthy Future for B.C. Families is striving to reduce greenhouse gas emissions from food transportation, through initiatives such as direct farm marketing and development of local food markets (British Columbia Ministry of Agriculture and Lands, n.d.). Lastly, in a report published by the American Dietetic Association (ADA), under Actions in Dietetic Practice, the report also supports local foods through the actions to “Encourage the consumption of locally produced foods through farm stands, farmers’ markets, food cooperatives, and community supported farms”, and to “Work to improve access to locally produced foods” (Harmon & Gerald, 2007, p. 1039). 9 Dietary choices requiring less packaging or packaging made from more environmentally sustainable resources, such as recyclable or compostable materials, represent another example of dietary choices that are considered to support environmental sustainability. Source reduction, including reduced packaging for transport and the purchase of products with minimal packaging, has been described as the preferred method for environmental approaches towards the management of municipal solid waste (Harmon & Gerald, 2007). Recycling and composting are also approaches that have been discussed as part of strategies for municipal solid waste management (Harmon & Gerald, 2007). Several Canadian and U.S. organizations have been developed to support the consumption of dietary choices with less packaging or packaging that is environmentally sustainable, such as compostable materials. For example, the Health and Sustainability Guidelines for Federal Concessions and Vending Operations published by the CDC suggest offering incentives for the use of reusable beverage containers, and recommend using bio-based and compostable trays, flatware, plates, and bowls (2012). As part of the CDC published guidelines, the “Vending Sustainability Requirements” also recommend providing preference to items that are packaged in compostable or recyclable packaging (HHS & GSA, 2012). In a second example, the AMA (2009) report of the Council on Science and Public Health recommends to “Minimize and beneficially reuse food waste and support the use of food packaging and products that are ecologically protective” (p. 11). The report by the American Dietetic Association also discusses the action to “Recycle food containers”, in addition to the action to “Encourage economic food purchasing that also reduces packaging waste” (Harmon & Gerald, 2007, p. 1039). Another example of a dietary choice that is often considered to be less environmentally sustainable in comparison to other choices is bottled water. An article published on behalf of the 10 Royal Swedish Academy of Sciences by Springer, discusses several of the potential negative environmental implications of bottled water, including packaging materials and pollution from fuel combustion in transportation and trading (Ferrier, 2001). The author concludes that bottled water is less energy-efficient in comparison to tap water and should not be viewed as a sustainable substitute. Due to the negative environmental implications of bottling water, the government and several organizations and institutions have also provided recommendations to minimize consumption of bottled water. For example, several Canadian universities are currently encouraging alternatives to the consumption of bottled water. The McGill Office of Sustainability provides several reasons for why bottled water should be avoided, including the creation of waste, the fossil fuels required for production of plastic bottles, and the greenhouse gases generated through transportation and distribution (2013). Some of the steps the University has taken to reduce bottled water intake include eliminating the provision of bottled water in residential dining, and setting-up high-volume tap water stations at several locations on the campus (McGill Office of Sustainability, 2013). In addition, in 2005, the Office of Greening Government Operations (OGGO) was developed within Public Works and Government Services Canada (PWGSC) (2013) to help accelerate the reduction of the environmental footprint of the government's operations through work with other federal departments. For example, one of the three Green Procurement Targets established by Environment Canada (2012) to reduce environmental impacts, as part of Greening Government Operations (GGO), includes a reduction in bottled water purchases from 2007–2008 levels by 90%. As another example, the report by the American Dietetic Association also discusses the action to “Drink filtered tap water vs bottled water” (Harmon & Gerald, 2007, p. 1039). 11 Despite recent efforts to reduce the negative impact of our dietary behaviours on the environment, there exist many areas where improvements can be made in order to improve the environmental implications of food systems. For example, regardless of current initiatives promoting the consumption of locally produced food, a large proportion of foods in BC and Canada are imported. In 2012, for instance, the total amount spent solely on world imports of edible vegetables and certain roots and tubers in British Columbia was $543,942,690 (Statistics Canada, 2014a), and in Canada, the total amount was $2,490,181,578 (Statistics Canada, 2014b). Furthermore, though recommendations are in place to minimize the generation of waste, in 2006, 956,968 tonnes of waste was produced by BC residents, and approximately 39.7% consisted of organic matter (BC Stats, 2010). Though organic matter often enters the waste stream, organic waste can often be used in the production of compost for use in areas such as agriculture (Stan, Virsta, Dusa, & Glavan, 2009). Therefore, there appears to be a continued need to support environmentally sustainable dietary choices and food practices in communities in Canada and BC, including those among schools and students. 1.2.3 Both Healthy and Environmentally Sustainable Dietary Choices Numerous governmental and health initiatives and recommendations have also been developed in Canada and the U.S. to address dietary choices that are considered to impact both health and environmental sustainability, including packaged foods and beverages, and highly processed items. SFNPs encouraging dietary behavioural outcomes reflecting both health and environmental sustainability among students may help to further support student health and reduce the negative impacts of dietary behaviours on envrionmental sustainability. In order to support health, Canada’s Food Guide recommends consuming vegetables and fruit prepared with little or no added fat, sugar or salt, choosing grain products that are low in fat, 12 sugar or salt, and selecting lean meats and alternatives prepared with little or no added fat or salt (Health Canada., 2007a). However, some processed foods, such as packaged baked products and salty snacks, contain high quantities of calories, fat, sugar, sodium and/or few nutrients, and are recommended to be limited (Dietitians of Canada, 2013). Many pre-packaged convenient snack foods (e.g. chocolate and biscuits) are described as being high in calories, fat, sugar, and salt, and as having health implications (McKinley, Oliver, & Livingston, 1995). Furthermore, one study evaluated the association between ultra-processed products and dietary quality and dietary intake of ultra-processed products in Canada. The article described ultra-processed food and drink products as “ready-to-consume/heat industry formulations manufactured from cheap ingredients directly extracted from whole foods, such as oils, fats, sucrose and flours, or processed from components extracted from whole foods such as high-fructose corn syrup, hydrogenated oils, a variety of starches, and the cheap parts or remnants of meat. These products are typically added of several preservatives and cosmetic additives, with little or no content of whole foods.” (Moubarac et al., 2013, p. 2242). Authors concluded that in comparison to processed culinary ingredients and a combination of minimally processed foods, ultra-processed products were unhealthy (Moubarac et al., 2013). Packaged and processed items are also often considered to be less environmentally sustainable dietary choices due to the energy and resources required for their production. The AMA (2009) report of the Council on Science and Public Health discussed the importance of increasing availability of foods with minimal processing for environmental sustainability as well as health, and the negative impact of packaging on the environment. With regard to processed foods, the report states that “Not only does the production and distribution of such processed food use fossil fuels and 13 generate emissions, but the plastic and paper packaging further depletes the environment of valuable natural resources.” (p. 4). Several Canadian and United States (U.S.) public health initiatives have recommended limiting intake of highly processed or packaged foods for either or both health and environmental sustainability. For example, in the Alberta Health Services Nutrition Guideline Food and Drinks High in Calories, Fat, Sugar or Salt (2012), as part of opportunities to reduce dietary intake of salt, the guideline recommends minimizing consumption of processed and packaged foods such as luncheon meats and packaged soups. The guideline also recommends limiting foods that are not included in Canada’s Food Guide food groups (frequently high in calories, sugar, salt, fat), such as chocolate, candy, cake, cookies and cake (sweet baked items), granola bars, potato chips, and snack foods (high in salt, fat, sugar) (Alberta Health Services, 2012). Many of these items reflect items that are frequently packaged and highly processed. In another example, in order to further support healthy dietary choices within schools, the 2007 revisions of the Guidelines for Food and Beverage Sales in BC Schools included the elimination of products that were considered highly processed, salted, and sweetened (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010). Furthermore, as part of the framework developed to improve the health of patients, communities and the environment, the AMA (2009) report of the Council on Science and Public Health recommended to “Increase our offering of fruit and vegetables, nutritionally dense and minimally processed, unrefined foods and reduce unhealthy (trans and saturated) fats and sweetened foods” (p. 11). The report by the American Dietetic Association also discusses the action to “Encourage consumption of fresh or minimally processed foods”, under Actions in Dietetic Practice, as well as the action to “Purchase foods with less packaging”, under Actions in the Community and at Home (Harmon & Gerald, 2007, p. 1039). 14 Regardless of current recommendations to limit dietary intake of processed and/or packaged foods, the Canadian Community Health Survey, Cycle 2.2, Nutrition (CCHS 2.2) report has shown that dietary intake of “other foods”, including snack foods high in fat and/or salt, which were recommended to be consumed in moderation by Canada’s Food Guide, represented a large proportion of the total caloric intake among Canadians (Garriguet, 2004). The “other” foods category in the report was described as including “fats and oils such as butter and cooking oils; foods that are mostly sugar such as jam, honey, syrup and candies; high-fat and/or high-salt foods such as chips (potato, corn, etc.); beverages such as soft drinks, tea, coffee and alcohol; and herbs and condiments such as pickles, mustard and ketchup” (Garriguet, 2004, p. 4). Many of the dietary choices listed in this category consist of items that would often be processed and packaged. The results of Canadian dietary intake of “other foods” from CCHS 2.2, revealed that among Canadians ages 4-18, 22.3% of caloric intake came from “other foods”, and represented the food group contributing the second highest proportion of daily calories to dietary intake among children and adolescents (Garriguet, 2004). The CCHS 2.2 report also found that among Canadians ages four and above, the number one dietary item contributing to the majority of calories within this group was soft drinks (11.3%) (Garriguet, 2004). 1.2.4 Healthy and Environmentally Sustainable Food Practices In addition to specific dietary choices among students that can have a potential influence on health and/or environmental sustainability, there are also many food practices which may have an impact on health or environmental sustainability. Current SFNPs may also have the potential to encourage healthy and environmentally sustainable food practices among students which in turn would have a benefit on student health and environmental sustainability. In this thesis, food 15 practices was a broad term used to describe behaviours that encompass both dietary intake and food waste disposal. Two examples of food practices related to health include breakfast and lunch consumption. Due to the established health benefits of consuming breakfast among children and adolescents (Shaw, 1998), the daily consumption of breakfast could represent a healthy food practice. Breakfast consumption among children and adolescents is important to health and development, and has also been connected with long-term health (Shaw, 1998). Different facets of cognitive functioning also appear to be affected when breakfast is not consumed (Shaw, 1998). As meal skipping is considered to have a harmful impact on adolescent health and is often common among adolescents (Pearson, Williams, Crawford, & Ball, 2012), a less healthy food practice might therefore be considered to be eating nothing for lunch on a school day. Food and beverage purchasing behaviours could also be regarded as food practices. For example, purchasing items at a convenience store, coffee shop, or a fast-food/takeout restaurant or food court, might represent a less healthy food practice, as literature has shown that these locations often provide less healthy dietary choices. One study revealed that convenience stores have a lower availability of healthful foods in comparison to supermarkets and grocery stores (Liese, Weis, Pluto, Smith, & Lawson, 2007). Healthy U (2014) in Alberta, Canada, also discusses Canada’s Food Guide recommendations to limit foods high in calories, sugar, salt, or fat, and describes food or beverage purchases, such as an iced coffee drink or a coffee shop muffin [which would typically be purchased in a cafe or coffee shop], to contain greater quantities of fat and sugar compared to items such as fruit or water. In addition, a study investigating fast-food intake concluded that fast food high in fat may lead to additional consumption of energy and fat, and reduced healthful nutrient intake (Paeratakul, Ferdinand, Champagne, Ryan, & Bray, 2003). 16 Two examples of food practices reflecting environmental sustainability include composting uneaten food items and consuming food items grown locally in the neighbourhood or community. Firstly, composting diverts biodegradable waste from entering landfills (Stan et al., 2009). Both the AMA and the American Dietetic Association have developed reports which have included recommendations related to composting. The AMA (2009) report of the Council on Science and Public Health includes the recommendations to compost, divert, and reduce food waste. The report by the American Dietetic Association also discusses the action to “Compost food scraps, lawn, and garden wastes” under Actions in the Community and at Home (Harmon & Gerald, 2007, p. 1039). Secondly, the food practice of selecting food items that were grown locally at home or in the community, including at school, may help to minimize the environmental impacts associated with other dietary choices, analogous to the reasons described for local dietary choices. For example, in comparison to locally produced items, non-locally grown foods often rely on greater quantities of fossil fuels for transportation (American Medical Association, 2009). Furthermore, non-locally grown foods often involve increased processing, including plastic and paper packaging and additional fossil fuel requirements (American Medical Association, 2009). 1.2.5 Summary of Healthy and Environmentally Sustainable Dietary Choice and Food Practice Recommendations The following recommendations represent current healthy and environmentally sustainable dietary behavioural outcomes and potential outcomes of participation in SFNPs. Current healthy dietary recommendations, which also reflect the key principles of Eating Well with Canada’s Food Guide (Health Canada, 2007a), focus on intake of more fresh and less processed and packaged items (such as items with little or no added fat, salt, or sugar) from the food groups. Healthy food practices include regular meals and limited purchasing at convenience food establishments. In addition, overall initiatives addressing the environmental sustainability of food systems demonstrate 17 support for dietary choices that are fresh and locally produced, involve minimal processing, rely on alternatives to bottled water, and those that use less packaging or packaging that is more environmentally sustainable, such as recyclable or compostable packaging. Food practices related directly to environmental sustainability might include consuming foods produced within the local community/neighbourhood, and composting uneaten food and beverage items. 1.2.6 Dietary Attitudes and Expectations In order to have a positive impact on healthy and environmentally sustainable dietary behaviours described above, factors influencing behaviours need to be taken into account when implementing strategies towards improving dietary intake. Health Behaviour Theory provides a conceptual model to represent how behaviour or changes to behaviour are influenced by potential mediators (Contento, 2007). The use of theory in the planning and development of programs is in agreement with the present emphasis on using interventions in medicine, behavioural medicine, and public health, that are evidence-based, and can assist in identifying outcomes for evaluation (National Cancer Institute, 2005). Several psychosocial theories have been developed in order to explain the constructs involved in health behavioural change, including Social Cognitive Theory (SCT) and the Theory of Planned Behaviour (TPB). SCT explains health behaviour as an outcome of reciprocal influence between personal, behavioural, and environmental factors (Contento, 2007). As part of personal factors, behaviour is influenced by outcome expectations, which are “our beliefs about anticipated outcomes from engaging in a behaviour or health-related lifestyle” (Contento, 2007, p. 116). TPB theorizes that the key influence on behaviour is behavioural intention, and that behavioural intention is influenced by attitude, subjective norm, and perceived behavioural control (National Cancer Institute, 2005). Attitudes, as one potential influence of behavioural intential, are defined as 18 “Personal evaluation of the behaviour (National Cancer Institute, 2005, p. 17). SCT and TPB behaviour therefore indicate the potential for attitudes and outcome expectations (or “expectations”) to have an influence on dietary behaviours, including dietary choices and food practices, among children and adolescents. Yet, in a review of psychosocial correlates of dietary intake among children and adolescents, authors found that a consistent relationship was not found between dietary outcomes and outcome expectations (McClain, Chappuis, Nguyen-Rodriguez, Yaroch, & Spruijt-Metz, 2009). Furthermore, in the review, research evaluating attitudes also did not reveal consistent relationships with all dietary outcomes investigated, such as fruit, fruit juice, and/or vegetables, though a negative association was found between attitude towards healthy eating behavior and “sugar snacking” (McClain et al., 2009). Nevertheless, the authors described that “Research has repeatedly shown that theory-based interventions that are guided by relevant behavioral theories are more likely to significantly impact dietary behaviors in youth [11-13].” (McClain et al., 2009, p. 2 (start page 54)). Due to the potential for psychosocial outcomes to influence dietary behaviours, many diet-related interventions have therefore focussed on evaluating psychosocial constructs, including dietary attitudes and expectations. Research on school interventions has shown that attitudes and outcome expectations have acted as mediators in changes to dietary behaviours. In a study aiming to review and critique current research of theoretical mechanisms of changes to dietary behaviors in interventions among youth, authors reported that “Self-efficacy and outcome expectations were the mechanisms most consistently associated with dietary behavior change” (Cerin et al., 2009, p. 309), and that “only attitude/outcome expectancies were identified as mediators in multiple interventions, age groups, and dietary outcomes” (p. 315). Therefore, SFNPs targeting psychosocial outcomes, 19 including dietary attitudes and expectations, may have a positive impact on dietary behaviours among students. 1.2.7 Theoretical Framework to Describe Associations between Participation in SFNPs and Dietary Psychosocial and Behavioural Outcomes The theoretical framework for this thesis proposed that participation in a particular SFNP may result in an association with specific dietary behaviours indirectly through associations with dietary psychosocial outcomes or from the incorporation of specific dietary behaviours into a particular SFNP. Firstly, the aspect of the framework proposing that potential associations between dietary behaviours and participation in SFNPs may be related to associations between SFNPs and psychosocial outcomes was based largely on SCT and TPB, indicating the potential for psychosocial factors to have an impact on behaviours (Contento, 2007). The framework therefore suggested that participation in SFNPs may have a possible impact on psychosocial constructs, including dietary attitudes and expectations, which may in turn result in further encouragement of positive changes to healthy and environmentally sustainable dietary behaviours among students. Secondly, the framework proposed that participation in SFNPs may lead to associations with dietary behaviours by involving the direct provision of healthy and/or environmentally sustainable dietary choices (such as tasting locally grown foods) and/or opportunities to engage in food practices related to health and/or environmental sustainability (including composting). Therefore, students who have had opportunities to participate in a particular SFNP may more frequently report certain dietary behavioural outcomes, as a result of participation in the program, compared to students who have not been exposed to the SFNP. 20 1.2.8 Overview of School Food and Nutrition Programs Available in Vancouver In Vancouver, a variety of school food and nutrition programs have been integrated into schools which may help to promote healthy and/or environmentally sustainable dietary choices and food practices, including food or nutrition related activities, clubs, and teaching cafeterias. In addition to more traditional nutrition education curricula, including home economics, recently schools have also begun implementing new innovative programs and activities that provide education on multiple components of the food system cycle, in order to encourage healthy and environmentally sustainable dietary choices among students. The food system cycle approach to teaching about food and nutrition, allows students to make a connection between food, health and the environment, in recognizing that the steps involved in food production, processing, packaging, transportation, consumption and disposal, have a large impact on health, and environmental sustainability. One example of a current Vancouver project focussing on education related to the food system cycle and the promotion of healthy and environmentally sustainable dietary choices among students is the University of British Columbia (UBC) Think&EatGreen@School Project. The Think&EatGreen@School Project, which includes the study which collected the data analyzed in this thesis, is a community/university collaborative project in the UBC Faculty of Land and Food Systems, funded through the Community University Research Alliances (CURA) program provided by the Social Sciences and Humanities Research Council (SSHRC) (Think&EatGreen@School, 2012a). The project aims to address food system sustainability in the region, as well as adaptations to climate change in institutions, through the promotion of healthy and sustainable school food systems (Think&EatGreen@School, 2011). The project’s main objectives are to establish healthy sustainable school food systems through the following: 1) food and environment education across 21 the curriculum, 2) school growing areas that produce food to be consumed in schools, 3) functioning food waste compost and recycling systems, and 4) food programs that provide safe, healthy, and sustainable food for students (Think&EatGreen@School, 2011). In order to address these objectives, the project has supported many Vancouver schools in providing numerous activities to students that reflect different aspects of the food system, from the production of food, to the preparation of food, and to the management of food waste. Many of the project’s initiatives have included integrating UBC students in developing and/or delivering SFNP activities to Vancouver school students as part of their UBC course curriculum (Rojas et al., 2012). Furthermore, the project has assisted in helping to incorporate Vancouver School Board (VSB) schools, students and educators, through activities such as growing food in school gardens, cooking and tasting locally grown foods, and composting, through partnerships with numerous community partners, including Vancouver Coastal Health, Fresh Roots Urban Farm and the Environmental Youth Alliance (EYA) (Think&EatGreen@School Project, 2012b). Among the variety of school food and nutrition programs (SFNPs) available in Vancouver, seven main categories of SFNP activities were created for this study to categorize SFNPs currently available in Vancouver schools, which included: 1) Food preparation activities, 2) Choosing or tasting healthy foods, 3) Learning about Canada’s Food Guide, 4) Learning about foods grown in British Columbia (BC), 5) Gardening activities, 6) Composting activities, and 7) Recycling activities. In addition to learning about these activities as a class with other students, many students may participate in these SFNP activities independently at school. For example, as part of overall school gardening activities, students may be assigned the responsibility of watering a portion of the garden during lunchtime or afterschool on their own. As a second example, students may independently compost their uneaten food or recycle their beverage containers while at school. 22 1.2.8.1 Food Preparation Activities There are several current SFNPs in Vancouver that focus specifically on food preparation activities, such as learning how to cook or preparing healthy foods. For example, the grade 8 curriculum in the majority of Vancouver schools requires students to register in Home Economics: Foods and Nutrition 8 (personal communication with VSB, 2013), which provides students with knowledge and skills of basic food preparation methods (British Columbia Ministry of Education, 2007). However, in addition to teaching cooking skills, the course also includes a component related to healthy eating in accordance with Canada’s Food Guide (Health Canada, 2007a). A second example of a program involving food preparation offered in several Vancouver schools are teaching cafeterias, where students would typically prepare food in the school cafeteria (personal communications with VSB staff and Think&EatGreen@School co-investigators, 2012). For example, one secondary school in Vancouver has a Cooking Cafeteria where student chefs prepare daily meals (Vancouver School Board, 2011). The program trains approximately 160 students each year, several of which pursue cooking as a career following graduation (Vancouver School Board, 2011). A third example of a food preparation program offered in Vancouver, is Take a Bite of BC. This program is offered through the BC Agriculture in the Classroom Foundation in partnership with the BC Culinary Arts Association, BC agricultural commodity groups and BC producers (BC Agriculture in the Classroom Foundation, 2008b). The program involves incorporating locally grown products into secondary school teaching kitchens, by providing the opportunity for chef instructors to visit secondary schools. The program describes the opportunity for students to “gain experience working with fresh products and begin to develop an appreciation for farmers in their community as they connect with the foods that are grown around them and learn about the benefits of eating healthy, fresh and local” (BC Agriculture in the Classroom Foundation, 2008b, para. 2). A 23 fourth example of an activity involving food preparation implemented in the VSB, was a school project developed by the Think&EatGreen@School Project, entitled Preparing and Sharing: Food in the Classroom (Rojas et al., 2012). This activity, integrated into the course curriculum for the Land and Food Systems (LFS) 250 course, involved training UBC undergraduate students to deliver activities involving preparing and eating vegetables and fruits to VSB students. The aim of the activity was to help VSB students increase their interest in food preparation and their enjoyment of vegetables and fruit, as well as their enthusiasm towards trying new fruits and vegetables (Rojas et al., 2012). 1.2.8.2 Choosing or Tasting Healthy Foods Activities Many programs are now offered throughout the Vancouver School Board in order to provide opportunities to choose and taste healthy foods, such as the BC School Fruit & Vegetable Nutritional Program (BCSFVNP). The BCSFVNP, a second program offered through the BC Agriculture in the Classroom Foundation, allows students the chance to taste BC grown fruits and vegetables (BC School Fruit and Vegetable Nutritional Program (BCSFVNP), 2013b). The specific objectives of the program include: 1) to increase the consumption of local fruits and vegetables, 2) to increase the awareness of the health benefits of fruits and vegetables, 3) to increase the awareness of fruits and vegetables grown in BC, 4) to increase the awareness of the safe handling practices of fresh fruits and vegetables (BCSFVNP, 2013b). A second example of a current program providing students with the opportunity to both choose and taste healthy foods is the Farm to School. As “part of a broader Farm to Cafeteria movement in Canada - a movement that is working to bring local and sustainably produced foods into places where we work, learn, are healed and play”, Farm to School focuses on linking schools and local farms (Farm to School, 2008, para 7). The main goal of the program “...is to ensure children have access to fresh, local, nutritious, safe 24 and culturally appropriate foods while at school. Farm to School programs aim to improve student nutrition, and to provide students with educational opportunities about foods and the local food system, while supporting local farmers and the local food economy” (Farm to School, 2008, para. 2). The program includes several models on how to achieve the program’s overall goal. One example within the Farm to School food service models is the Farm to School Salad Bar, where local foods are brought to schools and prepared and served in a salad bar, providing students with the opportunity to both choose and taste healthy foods (Farm to School, 2012). In addition to the specific selection or tasting of healthy foods, activities involving choosing or tasting healthy foods might include grocery shopping activities, where students learn how to make healthy dietary choices when purchasing food at a supermarket or grocery store. Though education on grocery shopping does not appear to be specifically referred to in the Home Economics: Foods and Nutrition 8 subject curriculum, students may also be gaining the opportunity to learn how to grocery shop as part of this subject. For example, as part of a grocery shopping activity, students may learn how to choose foods from the four food groups in accordance with Canada’s Food Guide recommendations as part of a grocery store tour. In a second example, as a part of menu planning, students may learn how to write a grocery shopping list and participate in a grocery shopping activity where they select the items on their list from a grocery store. 1.2.8.3 Learning about Canada’s Food Guide Learning about healthy eating or Canada’s Food Guide is often integrated into the current BC curriculum for both elementary and secondary schools. For example, the Health and Career Education Grade 6, and Home Economics: Foods and Nutrition 8 subjects provide sections specifically relating to healthy eating or Canada’s Food Guide. For example, in Health and Career 25 Education Grade 6, the “Health” curriculum includes “Healthy Living” prescribed learning outcomes. The first learning outcome indicates that students will gain the knowledge to explain the benefits of reaching and continuing a healthy and balanced lifestyle, including the benefits of healthy eating practices (British Columbia Ministry of Education, 2006, p. 41). As part of this learning outcome, it is anticipated that students may be provided education on the healthy dietary recommendations provided by Canada’s Food Guide. In Home Economics: Foods and Nutrition 8, the “Nutrition and Healthy Eating” prescribed learning outcomes in the curriculum include: “use Eating Well with Canada’s Food Guide to plan simple, nutritious dishes and snacks” (British Columbia Ministry of Education, 2007, p. 20). Therefore, as part of participation in this subject, it is expected that students would be learning how to apply Canada’s Food Guide in making healthy dietary choices. 1.2.8.4 Learning about Foods Grown in British Columbia Several programs are now offered throughout the Vancouver School Board which include opportunities for students to learn about locally grown foods in British Columbia. For example, as part of the BC School Fruit & Vegetable Nutritional Program, lesson plans are available to teachers and educators who are interested in incorporating learning about agriculture and the fruits and vegetables provided by the program along with the fruit or vegetable snack offered to students (BCSFVNP, 2013a). In addition, Farm to School also discusses that the program offers students opportunities to develop their knowledge of the local food system (Farm to School, 2008). In addition, though not necessarily part of a set school course or subject curriculum, there may be many opportunities in the school year where VSB teachers provide students with education on BC grown foods. Examples might include learning about local plants as part of science, social studies, environmental or ecology subjects, or as part of an outdoor or fieldtrip activity. 26 1.2.8.5 Gardening Activities Many VSB schools have begun to provide opportunities for students to participate in growing food. In addition to the development of school gardens for growing food, several organizations and programs currently offer other activities for students to learn how to grow food, either through outdoor gardening programs or using alternative methods. At least three programs available in Vancouver are currently working with schools in developing school gardens and/or engaging students in gardening activities, who also partner with the Think&EatGreen@School Project (personal communication with Think&EatGreen@School, 2014), including: Fresh Roots Urban Farm Society, the Environmental Youth Alliance (EYA), and The Society Promoting Environmental Conservation (SPEC). Fresh Roots Urban Farm Society helps to create schoolyard market gardens which have many benefits including the provision of hands-on learning opportunities (Fresh Roots Urban Farm Society, 2013). The Environmental Youth Alliance (EYA) has a program entitled Growing Kids, which involves many activities related to school gardens, which include, but are not limited to: “garden expertise and consultation”, “experiential workshop delivery in classrooms from K-12”, “curriculum support and development”, and “support for student-lead garden clubs” (2014, para. 2). The Society Promoting Environmental Conservation (SPEC) has also currently begun the School Gardens Project to help in the development of organic school gardens throughout Vancouver (2013). SPEC has described that “Through the program, school children learn about food security and how to grow their own organic fruits and veggies, while teachers learn to incorporate fun and thought provoking agricultural topics into their curriculum” (The Society Promoting Environmental Conservation, 2013, School Gardens Project, para. 4). 27 Two examples of a current alternatives to standard outdoor school gardens, include the Spuds in Tubs program and Lasagna gardening. The Spuds in Tubs - Potato Tub Gardens for Schools in BC (Spuds in Tubs program) currently offered through the BC Agriculture in the Classroom Foundation. The Spuds in Tubs program offers an opportunity for teachers and students to plant and harvest potatoes grown in soil tubs, and provides schools enrolled with all the necessary tools and instructions for the program (BC Agriculture in the Classroom Foundation, 2008a). A second example of an alternative gardening activity, which was provided to schools by the Think&EatGreen@School Project, included the school project Food Production at School: Lasagna Gardening (Rojas et al., 2012). This project was incorporated into the UBC Land and Food Systems 250 course curriculum, and involved training undergraduate students to help school stakeholders develop a small garden by alternating layers of carbon-rich and nitrogen rich materials on a chosen school plot (Rojas et al., 2012). 1.2.8.6 Composting Activities In Vancouver, many schools have implemented composting activities. Several schools have composters that allow for the composting of fruit and vegetable scraps (personal communication with the VSB, 2013). A few schools also have Earth Tubs in place, that enable composting of fruit and vegetables, leaves, some paper plates, and a few additional items (Vancouver School Board, 2013a). Implementation of district-wide composting and collection of organic waste in Vancouver schools is also anticipated to begin in the 2013-2014 school year (personal communication with the VSB, 2013). There are also school composting resources available and programs that offer opportunities for students to participate in composting activities. For example, SPEC has developed a resource guide document which can assist schools in developing both a school garden and composting system (The Society Promoting Environmental Conservation, n.d.). In addition, as part 28 of the UBC Land and Food Systems (LFS) 250 course, the ThinkEatGreen@School Project incorporated a composting school project for VSB schools, to be delivered to schools by UBC undergraduate students, entitled Completing the Cycle: Vermicompost in Classrooms (Rojas et al., 2012). Vermicomposting relies on the use of red wiggler worms to decompose organic waste (Rojas et al., 2012). As part of the course, undergraduate students were trained to assist school stakeholders in gathering appropriate materials and constructing a vermicomposting system, in addition to providing instruction on its proper maintenance (Rojas et al., 2012). 1.2.8.7 Recycling Activities The VSB currently has a district-wide recycling program in place, which includes the provision of recycling bins and containers for paper, and mixed recyclables (such as cans and bottles), to schools in Vancouver, including bins and containers for student use (personal communication with the VSB, 2014). Therefore, due to the wide availability of recycling programs in Vancouver schools, students may have many opportunities at school to learn about recycling or participate in recycling activities. Students may also participate in school clubs, such as environmental clubs, which involve recycling activities (personal communications with VSB students, 2012). For example in the spring of 2013, the Environmental Club at one elementary school held a recycling assembly as part of an Earth Week Eco-Fair (Vancouver School Board, 2013b). 1.3 Literature on School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Psychosocial and Behavioural Outcomes Due to the potential role of school food and nutrition programs in having a positive impact on healthy and environmentally sustainable dietary psychosocial and behavioural outcomes, it is important to determine whether students are engaging in these activities, and whether differences in 29 participation are apparent between groups. There is therefore a present need to investigate current participation rates in SFNPs, in order to determine whether students report engaging in these programs, and whether opportunities to participate in these programs appear to exist. This research is particularly important to investigate among adolescents, as research has suggested that interventions should start before sixth grade, due to the consolidation of health behaviors early on (Kelder et al., 1994). Furthermore, it is also necessary to establish if variability exists among schools and in different activities within schools in terms of participation rates, as some schools may offer limited opportunities to participate in SFNPs compared to other schools within the same school district. Evaluating differences in participation by gender and school type (such as elementary school compared to secondary school) is also important in order to determine whether any inequalities exist in participation between students in these groups. The establishment of participation rates, variability in participation between schools and in different activities within schools, and differences in participation by gender and by school type, may be important to ensure equal opportunities for participation and engagement in activities among students. The measurement of health and environmental sustainability related dietary attitudes, expectations, choices and food practices among children and adolescents, particularly those specific to school days, is also essential. Due to the possible direct impact of schools on students’ health and the significant contribution of dietary intake at school towards total intake (British Columbia Ministry of Education & British Columbia Ministry of Health, 2005), as well as current initiatives supporting healthy and environmentally sustainable dietary behaviours among students, such as the BC Guidelines and the Vancouver School Board Sustainability Framework, it is important to investigate the specific healthy and environmentally sustainable dietary psychosocial and behavioural outcomes of students on school days. This research is key in helping to establish 30 whether current student dietary psychosocial and behavioural outcomes on school days reflect current recommendations promoting health and/or environmental sustainability, and whether improvements to school day outcomes are needed. Results will also help to determine whether further initiatives are warranted in schools in order to help encourage healthy and environmentally sustainable outcomes on school days. Furthermore, due to the potential for dietary behaviours in adolescence to impact long-term behaviours and long-term health (Story et al., 2002), measuring dietary psychosocial and behavioural outcomes among adolescents is of particular value. In addition to measuring participation in school food and nutrition programs, there remains a clear need to establish which programs reveal significant associations with student dietary psychosocial and behavioural outcomes related to health and/or environmental sustainability, particularly outcomes specific to school days and particularly among adolescents. This research is imperative in helping to assist in the development of and in making changes to SFNPs which may have a positive impact on healthy and environmentally sustainable dietary psychosocial and behavioural outcomes among students. This section will review the current literature (in the English language) on participation in school food and nutrition programs, healthy and environmentally sustainable dietary attitudes, expectations, dietary choices and food practices, among children and adolescents, in addition to associations between participation in SFNPs and student healthy and environmentally sustainable dietary psychosocial and behavioural outcomes. 1.3.1 Participation in School Food and Nutrition Programs and Differences by Gender and School Type Literature was reviewed on rates of participation in school food and nutrition programs among students in the following activity categories: food preparation activities, choosing or tasting 31 healthy foods activities, learning about Canada’s Food Guide (or an alternative food guide), learning about what foods are grown in British Columbia (or locally), gardening, composting, and recycling. Studies evaluating participation in specific food or nutrition related clubs, or teaching cafeterias were also searched. Four studies were retrieved that focussed on participation in food and/or nutrition related programs among students. The first study investigated participation in both public and private schools in nutrition education programs and formal classroom education on nutrition, as well as a combination of gardening and Farm to School activities, using cross-sectional nationally representative U.S. survey data collected through a program entitled Bridging the Gap (program funding provided by the Robert Wood Johnson Foundation) (Turner & Chaloupka, 2012). Between the years of 2006-2007 and 2009-2010, the authors found a statistically significant increase in gardening or Farm to School program activities in public schools from 15.8% to 33.1%. Formal classroom education on nutrition education in public schools also increased from 60.7% to 67.6% (Turner & Chaloupka, 2012). Nevertheless, this study only measured availability of these programs among schools, and not student participation rates in the programs within schools. Furthermore, as participation in gardening or Farm to School program activities was combined, it was not possible to determine the total percentage of schools who participated in each activity, nor whether the overall increase in participation found resulted from an equal increase in participation in both activities or only an increase in participation in one activity. A second study reported participation rates in food preparation among students in grades 4-8 in southwestern Ontario, Canada, recruited from one elementary school and several after-school programs and sports programs (Woodruff & Kirby, 2013). The authors found that half of students reported involvement in food preparation 1-6 times per week (Woodruff & Kirby, 2013). 32 Nonetheless, this study evaluated general participation in food preparation activities and not food preparation specifically at school. Thirdly, a dissertation was retrieved investigating participation in school recycling activities following implementation of a school recycling program among students from seven schools (elementary, intermediate and secondary) in the Clovis Unified School District in California, U.S. (Zelezny, 1998). The study included a questionnaire to ask students how much they participate in school recycling using a 5-point scale from “very often” to “never”, including a sixth response option of “I don’t know”. Participation in school recycling was measured using the average rating indicated by students on the self-reported scale (Zelezny, 1998). The author found that the mean participation rating reported by students following the recycling program, was 3.11 (Zelezny, 1998). Nevertheless, it does seem to be possible to determine the total percentage of students from the sample who participated in recycling at the school from the mean student rating reported, as the author did not appear to distinguish the number of students who reported participating from the number of students who reported “never” or “I don’t know”. The last article was a study recently published on Canadian school food and eating environments by Browning, Laxer, & Janssen (2013). One component of the study included an evaluation of healthy eating education in primary, mixed, and secondary schools, as well as in schools of either rural, urban, or large urban status, in 407 national schools who were involved in the 2009/2010 Canadian Health Behaviour in School-aged Children (HSBC) survey cycle (Browning et al., 2013). Healthy eating education evaluated included cooking classes, gardening activities, field trip to a farmers’ market, field trip to a grocery store, and healthy eating media literacy. Results of education in secondary schools revealed that 77.1% of secondary schools offered cooking classes, whereas only 12.8% offered opportunities in gardening activities (Browning et al., 33 2013). These findings suggest that cooking classes are more often integrated into the curriculum in Canadian secondary schools in comparison to gardening activities. Nevertheless, as percentages represented the proportion of schools who offered these healthy eating education items and not the number of students who participated in each school, it is therefore not possible to determine whether the majority of students at these schools have received opportunities to participate in healthy eating education items offered, or if only a few select students are participating in these education items. Results of the four studies described reveal that though efforts have been made to measure participation in food or nutrition related programs among youth, previous literature does not appear to have specifically measured participation rates among students. Research is therefore needed in order to establish student participation rates in various SFNPs, including whether variability exists in participation in activities between schools, and whether participation rates differ between activities within individual schools. In addition to the apparent limited number of studies evaluating rates of participation in SFNPs among students, only a few studies have assessed whether participation in SFNPs differ by gender. The study by Zelezny (1998), investigating school recycling, revealed that girls reported significantly higher participation in school recycling after the intervention compared to boys. For example, the mean participation reported following the intervention on the 5-point scale from “very often” to “never” (including a 6th response option of “I don’t know) was 3.31 for girls and 2.91 for boys (Zelezny, 1998). The study by Woodruff & Kirby (2013) also included an evaluation of frequency of participation in food preparation between boys and girls, and found that no significant differences in participation were reported between boys and girls. Though, as previously discussed, food preparation did not appear to be specific to activities at school. 34 With respect to measuring differences in participation in SFNPs by school type, though not specifically measuring differences between elementary and secondary school students, the study by Woodruff & Kirby (2013) found a higher reported frequency of involvement in food preparation in higher grades (Gr. 7-8 = 7.3, Gr. 4-6 =5.1, p =0.03). (Woodruff & Kirby, 2013). In addition, the study by Zelezny (1998) found a significant difference in reported participation in recycling between elementary, intermediate, and high school students following the intervention. Results revealed that after the intervention, the mean participation in school recycling reported by elementary, intermediate, and high school students, was 3.41, 2.85, and 2.69, showing higher reported participation among elementary school students (Zelezny, 1998). The findings of these two studies are important in identifying that potential inequalities exist in opportunities to participate in specific SFNPs between grade or school types, and indicate a possible need to develop strategies to promote equal participation among student groups. 1.3.2 Healthy and Environmentally Sustainable Dietary Attitudes and Expectations The following two studies evaluated attitudes towards dietary choices among youth, one of which investigated attitudes specific to school days. The first study, by Gosliner, Madsen, Woodward-Lopez, & Crawford (2011), focussed on the measurement of attitudes towards food and beverage purchasing at school. Students completed a questionnaire which included the question “How important is it to you to be able to buy the following food items at school?”. Results revealed that students rated fresh fruit highest (69%) in terms of being important or very important to be able to buy at school (Gosliner et al., 2011). The second and third highest rated items were followed by green salad (55%) and other vegetables (53%). Less healthy items such as candy (28%) and soda (31%) were not rated as high in terms of their importance (Gosliner et al., 2011). Nevertheless, this study measured attitudes specifically towards food and beverage purchases made at school, and 35 therefore did not capture attitudes towards overall purchasing on school days, including those made outside the school setting. In the second study, authors evaluated perspectives among adolescents towards food production practices and whether they are related to dietary behaviours (Bissonnette & Contento, 2001). The study showed that a high percentage of students rated healthfulness of food as important to them (83.9%) (Bissonnette & Contento, 2001). These studies indicate that the majority of students report positive health-related dietary attitudes. Of the limited number of studies looking at environmentally sustainable dietary attitudes among youth, study results appear to show that the majority of youth do not report positive dietary attitudes related to environmental sustainability. In a study that reported attitudes among adolescents from data obtained from 2516 adolescents who participated in Project EAT-II (a follow-up study to Project EAT: Eating Among Teens conducted in Minnesota), the study showed that overall 20.9% of participants reported that it was somewhat or very important that their food was locally grown and 29.8% stated that it was important that their food was non-processed (Robinson-O'Brien, Larson, Neumark-Sztainer, Hannan, & Story, 2009). Also, in the study previously described by Bissonnette & Contento (2001), 80% of respondents stated that whether food is grown nearby was not personally important to them. However, attitudes measured were not directly related to food and beverage purchases on school days. There also appears to be limited research investigating attitudes towards caring about the impact of food choices on the environment among students. However, in the previously mentioned study by Zelezny (1998), investigating recycling activities, students were asked about their level of environmental concern. From the question included in the questionnaire, environmental concern appeared to have been measured on 6-point likert scale from “Extremely concerned” to “Not at all concerned”, including the sixth option of “I don’t know”. Mean self-rated overall environmental 36 concern reported among students prior to the intervention was 3.39 (Zelezny, 1998). However, this question was not specific to the environmental implications of food choices, and therefore appeared to only reflect general student concern for the environment. Health-related outcome expectations of dietary items among children and adolescents were evaluated in the following two studies. One study investigated the impact of whole-grains on outcome expectations related to health (Rosen, Burgess-Champoux, Marquart, & Reicks, 2012). For example, students were asked whether they agree that whole grains may provide specific benefits, including that whole grains are “good for them, helped them be strong, provided energy, kept their heart healthy”, using a 5-point scale from ‘‘Strongly disagree’’ to ‘‘Strongly agree’’. Authors discovered that mean outcome expectations scores were high (mean +/- SD = 3.7 +/- 0.4) (Rosen et al., 2012). Nevertheless, as outcome expectations related specifically to whole-grains, it is not possible to establish whether participants believed that overall dietary choices would have an impact on health. The second study evaluated attitudes pre and post participation in either of two nutrition-related courses among high school students from a school in North Texas (Watson, Kwon, Nichols, & Rew, 2009). The attitude question included in the study questionnaire was similar to questions used for health-related outcome expectations questions applied in other studies examining expectations associated with dietary choices, such as those previously described in the study on whole grains. Participants were asked whether they agreed with the statement “Foods I eat now will impact my health now/as an adult” (on a 5-point likert scale from 1 = strongly disagree to 5 = strongly agree) (Watson et al., 2009). At baseline, results revealed that the mean attitude score for the statement that foods will impact health was 4.5 in the intervention group and 4.7 in the control group (Watson et al., 2009). The results from these studies indicate that students often report positive attitudes or expectations related to the impact of dietary choices on health. 37 In addition to the limited research measuring environmentally sustainable dietary attitudes, only a few studies have investigated environmentally sustainable expectations among children and adolescents. Nevertheless, the study by Bissonnette & Contento (2001) did evaluate beliefs about locally grown foods and whether participants agreed that they had an impact on the environment. The questionnaire phrasing used in the question measuring beliefs appeared to be addressing outcome expectations regarding locally grown dietary choices. The results showed that there was a fairly equal proportion of adolescents who responded that they “disagree somewhat” or “agree somewhat” that locally grown foods had an impact on the environment, and approximately 30-40% stated they “did not know” (Bissonnette & Contento, 2001). However, as the question focussed specifically on local food, it is difficult to evaluate participants’ perception of the overall impact of food choices on the environment. 1.3.3 Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days Two studies were found that investigated school day dietary choices among children and adolescents. Both studies looked at dietary categories, either on school days or during school lunch. The first study assessed school day intake of dietary choice categories over five days among an African-American student population in Philadelphia, Pennsylvania (McDuffie & George, 2009). Authors defined school day in the questionnaire as “The time between leaving home in the morning and arriving at home after school”, in order to include “food obtained from the neighborhood while going to and from school, as well as that consumed from the school's resources” (McDuffie & George, 2009, p. 117). The study found that over five days, the mean total reported frequency of consumption of nutrient-dense foods (14.82) was approximately half the reported frequency of consuming energy-dense foods (27.13) (McDuffie & George, 2009). Results also revealed that overall during a five day period, no nutrient-dense foods, including milk and salads, were consumed 38 greater than two times. In contrast, four categories of energy-dense foods were consumed two times or more, which included sweets/desserts, candy, salty snacks, and soft drinks (McDuffie & George, 2009). The second study investigated school lunch dietary choice categories of Canadian adolescents from Southern Ontario, Canada (Woodruff, Hanning, & McGoldrick, 2010). The study revealed that a large number of participants reported consuming sugar-sweetened beverages during lunch (46%), compared to items such as milk (9%). Though this study provided information regarding dietary choices at school, it did not represent overall dietary intake of students during school days. Nevertheless, overall, these two studies indicate that students may frequently be choosing less healthy options while at school or on school days. A few studies have investigated healthy dietary food practices among youth, including food practices of Canadian and North American students, such as frequency of consuming breakfast and lunch and purchasing of food and beverages at convenience food establishments on school days. A study by Storey et al. (2009) evaluated food practices among students in grades 7-10 in Alberta, Canada, including frequency of breakfast and lunch consumption. The study findings showed that among students who were considered to have average diet quality, the mean breakfast frequency reported (on a 5-point scale from never=1 to everyday= 5) was 4.34, and the mean frequency of lunch reported for this group was 4.69 (Storey et al., 2009), indicating that students appear to consume breakfast and lunch close to daily. Furthermore, the authors evaluated consumption of items outside of the home from different venues. On a 5-point scale from rarely or never=1 to once a day=5, results revealed that among students considered to have average diet quality, the means reported for fast food/take out, snack bars, convenience stores were 2.25, 2.15 , and 2.42, respectively (Storey et al., 2009). In the study by McDuffie & George (2009), authors also investigated the proportion of students who reported purchasing lunch outside of the school. The 39 study found that the percentage of students who purchased lunch outside of school, one day per week or more over five-days, was greater than 30% (McDuffie & George, 2009). However, this study did not specify the types of establishments where students were purchasing foods. Furthermore, students only reported on purchasing over a five-day period, which may not reflect typical purchasing behaviours over a longer length of time, such as over the past month. Results of these studies indicate that students may frequently purchase less healthy options or lunch (on school days) from convenience or other food establishments. Only a limited number of studies have evaluated environmentally sustainable dietary choices or food practices among youth, such as intake of local foods and foods and beverages in recyclable or compostable packaging. In the article by Bissonnette & Contento (2001), authors included the measurement of consumption of food from a farmers’ market or farm stand among adolescents. Results indicated that 71% of adolescents included in the study reported previously consuming food “from a nearby farm stand or farmers’ market” (p. 76). Nevertheless, this study did not evaluate how frequently the food was consumed, nor did results reflect school day dietary intake. The one study retrieved investigating dietary behaviours, including the frequency that participants report that they “Buy/eat food that has been grown locally (i.e. preferably Victoria)”, “avoid purchasing products in non-environmentally friendly packages (e.g. plastic packaging, excess packaging)”, or “Compost household food scraps”, was among adult consumers in Australian (Lea & Worsley, 2008). Therefore, available research on environmentally sustainable dietary choices or food practices among children and adolescents has evaluated dietary intake of locally produced items, and has shown that the majority of adolescents have had the opportunity to consume items from a local farm stand or market. 40 In addition to the limited research investigating school day healthy and environmentally sustainable dietary intake and food practices among children and adolescents, there also appear to be very few studies evaluating dietary behaviours among children and adolescents in Vancouver, BC. For example, one study evaluating dietary intake among Vancouver children specifically investigated sodium intakes of children between the ages of 1-6 (Mulder, Zibrik, & Innis, 2011). Results revealed that the sodium intake of 91.6% of the children was above recommendations for their age (1000 or 1200 mg/day) (Mulder et al., 2011). Though this study did identify dietary choices that contribute to sodium intake among Vancouver children, there does not appear to be research investigating overall dietary choices of older children and adolescents in Vancouver, particularly those specific to school days. 1.3.4 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations A few studies appear to have examined associations between participation in the seven categories of SFNPs discussed and dietary attitudes and expectations. Results indicate the potential for participation in many SFNPs to have a positive impact on dietary psychosocial outcomes. In terms of the impact of food preparation activities on attitudes or expectations, one study was found that investigated attitudes towards liking or willingness to try specific foods following participation in a nutrition workshop (Bisset, Potvin, Daniel, & Paquette, 2008). The study included a survey of grade 5 students who had participated in the program for up to 6 years, and a control group consisting of grade 6 students from the same school who had not participated. Nutrition workshops, held 8 times each year, were led by community dietitians. Workshops included a nutrition theme, as well as a featured food item and an opportunity to participate in preparation of a recipe and tasting experience. Positive attitudes towards food were described as being measured 41 through the number of food items that participants reported liking or being willing to taste (Bisset et al., 2008). Response options for “liking or being open to tasting less common foods” were provided on a scale from low=0 to high=10 (Bisset et al., 2008). The mean response among participants was significantly higher compared to non-participants (6.2 vs. 5.6, p<0.01) (Bisset et al., 2008), showing a potential positive impact of the workshop on attitudes towards less common foods. Very limited research has evaluated associations between participation in choosing or tasting healthy foods activities on dietary attitudes and expectations. However, one study was found that investigated attitudes towards fruit and vegetables, as part of a pilot fruit and vegetable program among students from Northern Ontario, Canada (He et al., 2009). The program included three groups: 1) Intervention I = Free Fruit and Vegetable Snack (FFVS) with Enhanced Nutrition Education; 2) Intervention II = FFVS only; and 3) Control group (He et al., 2009). Though the study did not specifically report measuring outcome expectations with regard to the impact of dietary choices on health, the study appeared to evaluate students’ awareness of a diet-disease relationship related to dietary intake of fruit and vegetables as part of a series of attitude questions towards fruits and vegetables. For example, students were asked to report their level of agreement with the statement “Eating fruit and vegetables could help prevent heart disease” on a scale from fully disagree to fully agree (He et al., 2009). Of a possible range of scores from 5-25 on the series of attitudes towards vegetable and fruit consumption, the mean attitude outcome scores between the three groups were similar (Intervention I (21.6), Intervention II (21.4), and the control group (21.5)), and showed no statistically significant differences (He et al., 2009). Authors concluded that most students had positive attitudes towards fruit and vegetables (He et al., 2009). The study results suggest that the program may not have a significant effect on dietary attitudes. Nevertheless, the specific study attitude related to the effect of fruit and vegetables on health pertained only to the 42 impact of dietary intake of fruit and vegetables on heart disease prevention, and not to the impact of overall dietary choices. The attitude was also only with respect to the impact of food choices towards the prevention of heart disease, and did not reflect outcome expectations or attitudes towards the impact of food choices on overall health. Lastly, the study attitude score appeared to reflect a combination of attitudes related to fruit and vegetables and not only the impact of dietary intake of fruit and vegetables on heart disease prevention. Therefore, the specific measurement of associations between general dietary choices and psychosocial outcomes related to general overall health may have yielded different results. No literature was found evaluating associations between learning about Canada’s Food Guide or other food guides and dietary attitudes or expectations. Nevertheless, a few studies have been conducted on the impact of nutrition education on dietary attitudes. For example, in the study by Watson et al. (2009), which included an evaluation of attitudes towards nutrition among students, students participated in one of two nutrition-related courses over 18 weeks, which included education related to healthy eating and physical activity, weight management, and lessons on major nutrients and functions. Nutrition subject matter integrated into both courses included dietary guidelines and the food guide pyramid. Using a 5-point likert scale from “strongly disagree” to “strongly agree”, students were asked to report whether they agreed with the following statements: “I choose foods based on nutritional content” and “Foods I eat now will impact my health now/as an adult” (Watson et al., 2009). Results did not reveal significant differences after the intervention in either the control group or the intervention group for these two attitudes (Watson et al., 2009). There were also no statistically significant differences in all attitude questions between the control and intervention group pre-test (Watson et al., 2009). However, a significant increase was found in the intervention group for attitudes towards interest in nutrition and health and “perceived confidence of 43 making good food choices” following the intervention, whereas no significant differences were found pre and post intervention in the control group (Watson et al., 2009). Overall, however, authors stated that study results suggest the potential of high school nutrition education to have a positive impact on attitudes among students (Watson et al., 2009). Limited research has investigated whether learning about locally grown foods has an impact on dietary attitudes or expectations. One study was found, however, that evaluated whether a game for high school students, which focussed on the benefits of eating locally grown food and colourful fruits and vegetables, would affect student attitudes towards these foods (Green et al., 2003). Though not specifically referred to in the study as measurement of a dietary attitude or expectation, students were asked whether there are “environmental effects of food choices”. Results revealed that prior to the intervention, only 13% of students agreed that there are “environmental effects of food choices”. However, following the intervention, 54% of students reported that they agreed (Green et al., 2003), indicating a potential positive impact of participation in the game on agreement with “environmental effects of food choices”. Though some research appears to have measured associations between participation in gardening and student dietary attitudes, studies evaluating gardening interventions among youth appear to often measure attitudes through students’ reported preferences towards vegetables, such as their willingness to taste certain vegetables. For example, one study evaluated the impact of school gardening among students in grades 5-6 in the Hunter Region, New South Wales, Australia, by comparing differences between students’ willingness to taste specific vegetables and whether they would eat certain vegetables as a snack (Morgan et al., 2010). The study involved three groups: 1) nutrition education and gardening, 2) nutrition education only, and 3) a control. Results showed significant differences between the nutrition education and gardening group compared to the other 44 two groups with respect to their willingness to taste “capsicum [peppers]” (p=0.04), broccoli (p=0.01), tomato (p<0.001) and pea (p=0.02) (Morgan et al., 2010). In addition, in comparison to the nutrition education only and control groups, the nutrition education and gardening group also reported a statistically significant higher likelihood that they would eat broccoli (p<0.001) and pea (p<0.001) as a snack (Morgan et al., 2010). Results of this study are also supported by overall results of a review of garden-based nutrition-education programs, which concluded that participation in garden programs may have the potential to increase willingness to taste fruits and vegetables and youth preferences for fruits and vegetables among those with currently low preferences (Robinson-O'Brien, Story & Heim, 2009). Research to date on gardening activities among youth clearly provide evidence suggesting a potential positive impact of participation in gardening on dietary attitudes, yet there do not appear to be many previous studies investigating the impact of gardening on student dietary expectations. There appear to be some publications discussing the outcomes of participation in school composting activities. For example, one article published on student participation in composting activities concluded that students had gained knowledge about the composting process (Estes & Fucigna, 2013), but they did not appear to discuss student environmentally sustainable dietary attitudes or expectations before or after participation in composting activities. Therefore, little research if any appears to have conducted a formal evaluation of the impact of participation in composting activities on dietary attitudes or expectations. One study was found that assessed whether participation in school recycling activities was associated with attitudes related to the environment. The study by Zelezny (1998), previously introduced, investigated the mean self-rated environmental concern reported by students both prior to and following implementation of the school recycling program. Contrary to what was expected, 45 the study found that the mean rating significantly decreased following the intervention from 3.39 in 1994 to 3.24 in 1995 (p ≤ 0.01) (Zelezny, 1998). Nevertheless, the environmental concern reported by students was not specific to concerns regarding the impact of dietary choices on the environment. Therefore, research investigating dietary expectations associated with recycling appears to be needed. 1.3.5 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days Limited research exists evaluating associations with participation in the seven categories of SFNPs described and healthy and environmentally sustainable dietary choices and food practices. However, research to date evaluating associations between participation in SFNPs and dietary behavioural outcomes, including dietary intake specific to school, has shown a potential positive impact of SFNPs on dietary behavioural outcomes among students. Very few studies have specifically assessed the associations between participation in school food preparation activities and dietary choices or food practices. However, one study was found that did investigate whether a school cooking intervention, which included a cooking session with a chef, would have an impact on vegetable consumption among primary school children (Caraher, Seeley, Wu, & Lloyd, 2013). The study showed that children in the intervention group reported a significantly higher vegetable intake after the cooking session. On a 4-point scale from “ate it more than once” to “I did not eat it and did not want to”, score for vegetable intake rose from 2.24 points pre-intervention to 2.46 points post-intervention. Furthermore, no significant changes were found in the control group (Caraher et al., 2013). These results indicate the potential for the school cooking intervention to have a positive impact on vegetable intake. 46 A few studies have investigated whether school activities involving choosing or tasting healthy foods have an impact on student dietary choices or food practices. In the study by He et al. (2009) investigating the pilot fruit and vegetable program in Ontario, Canada, authors also investigated whether the program had an impact on students’ fruit and vegetable intake. Results demonstrated that intake of fruit and vegetables at school was significantly greater among the Intervention I group in comparison to the control group. In addition, though not statistically significant, there was also a higher intake among the Intervention II group compared to the control (He et al., 2009). These findings overall suggest a potential positive impact of the program interventions on student consumption of fruit and vegetables at school. Though limited to no research specifically evaluating the impact of learning about Canada’s Food Guide (or any other published food guide) on dietary choices or food practices among students appears to exist, literature has discussed outcomes of programs that specifically involved nutrition education (some which referred to education related to the food guide pyramid). One study found assessed the effects of nutrition education on knowledge and dietary choices among students in grades 2 and 3 (Powers, Struempler, Guarino, & Parmer, 2005). This study also included an evaluation of knowledge of the food guide pyramid as part of nutrition knowledge assessment, indicating that education on the food guide pyramid may have been integrated into the nutrition education study component. Following the intervention, there was a significant increase in the dietary intake of the following: juice at breakfast, vegetables and cheese at lunch, and fruit at supper and at snack. In addition, results showed that for the control group, there were no significant improvements to dietary behaviours before and after the intervention (Powers et al., 2005). The study by Watson et al. (2009), investigating the impact of a high school-based nutrition course (which included core nutrition topics, such as food guide pyramid) on student nutrition knowledge, 47 attitudes, and food consumption behaviors, also showed significant changes to students’ dietary intake following the intervention. Authors evaluated dietary intake of several food categories including meat items, fried meat items, milk, vegetables, fruits, frozen dessert, sweet rolls, donuts, cookies, brownies, pies, or cake, as well as breakfast consumption. Prior to the intervention, the intervention and control groups did not differ on the dietary variables. However, following the nutrition course, the intervention group did show a significant increase in milk intake and consumption of breakfast (Watson et al., 2009). Results of breakfast and milk consumption also differed significantly between the intervention and control group after the intervention (Watson et al., 2009). Similar to the article by Powers et al. (2005), results of this study also showed that no significant changes to behaviours occurred in the control group (Watson et al., 2009). Findings from these two studies indicate the potential for nutrition education, which may incorporate the food guide pyramid, to have a positive influence on healthy dietary behaviours. A few reports and publications appear to have discussed outcomes of programs that specifically included an educational component to teach students about locally produced foods and their environmental impact. For example, the program Fresh from the Farm, in Illinois, offered through the advocacy group Seven Generations Ahead (SGA), incorporated education on the benefits of organic, fresh, and locally grown food, on health and the environment (Kish, 2008). This program, however, also included activities such as planting, harvesting and composting on the farm, and also provided weekly opportunities to taste fresh vegetables and fruit. Authors concluded that evaluations of the program provided evidence of a significant increase to students’ knowledge of locally grown foods and healthy dietary intake (Kish, 2008). Furthermore, the authors stated that students had reported an increased understanding of the importance of consuming fresh vegetables and fruit, and as well as greater intake of healthy foods (Kish, 2008). Though results suggest that 48 participation in activities involving learning about local foods have a positive influence on healthy dietary intake, as results themselves, including the specific dietary outcome variables measured, and statistical significance of results, were not presented, little empirical evidence appears to exist in this area of research. Several studies have investigated whether participation in school gardening has a positive impact on dietary behaviours. For example, in a study by McAleese & Rankin (2007), involving grade 6 students in southeast Idaho, students who were involved in gardening activities in addition to nutrition education curriculum, showed a greater increase in consumption of fruit (1.13 servings per day, P<0.001) and vegetables (1.44 servings per day, P<0.001), that was significant in comparison to students only provided nutrition education curriculum and to students in the control group. Furthermore, authors reported that no significant changes in vegetable or fruit intake occurred in the nutrition education only or control groups (McAleese & Rankin, 2007). This study shows the potential for participation in nutrition education activities involving gardening to have a positive impact on intake of vegetables and fruit. These results are also supported by the review of garden-based nutrition-education programs by Robinson-O'Brien, Story & Heim (2009), which concluded that overall garden programs have the potential to improve fruit and vegetable intake among youth. Studies on school gardening have also evaluated dietary intake of vegetables specifically at school. For example, a study among grade 6 students in the San Francisco Unified School District found that dietary intake of vegetable varieties at school significantly increased among students exposed to “garden-based learning experiences” compared to students in a control group who were not exposed to gardening (Ratcliffe, Merrigan, Rogers, & Goldberg, 2011). Nonetheless, as the “garden-based learning experiences” involved several activities in addition to gardening, including 49 nutrition education and cooking meals from foods grown in the garden, there is a possibility that activities other than gardening had a greater impact on the significant positive changes observed in dietary choices among students. In addition, in the review of garden-based nutrition-education programs by Robinson-O'Brien, Story & Heim (2009), despite the conclusion regarding the potential for garden programs to improve fruit and vegetable intake among youth, authors indicated a need for future research to evaluate the influence of garden-based nutrition-education programs on dietary intake, due to the limited availability of evidence-based, peer-reviewed, and appropriately designed studies (Robinson-O'Brien, Story & Heim, 2009). Therefore, though literature has suggested a potential positive impact of participation in gardening activities on student dietary behavioural outcomes, future evidence-based research, and research specifically evaluating school day dietary behavioural outcomes, is still needed. Though there does not appear to be research investigating whether associations exist specifically between participation in composting activities and dietary choices or food practices, there have been a few publications regarding SFNPs that have incorporated composting activities as part of the overall program. For example, as previously discussed, the program Fresh from the Farm, which included farm composting activities as part of education focussing on local foods and their effect on the environment, was stated to have a positive impact on healthy dietary intake (though statistical results to support this conclusion were not provided) (Kish, 2008). Nevertheless, similar to the study on garden-based learning experiences conducted by Ratcliffe et al. (2011), as the program in this report included several activities and educational components, it does not appear possible to determine whether the specific composting activities within the program were an important factor resulting in the positive changes observed in dietary outcomes. 50 The one study found investigating the impact of school recycling activities on student outcomes (Zelezny, 2008), appears to have only evaluated the impact of recycling on attitudes and recycling behaviours. As a result, there does not appear to be research assessing whether participation in recycling is associated with environmentally sustainable dietary choices or food practices. 1.3.6 Literature on Specific SFNPs Implemented in Vancouver and North America In addition to the limited research on general categories of SFNPs and their associations with dietary psychosocial and behavioural outcomes, despite the implementation of various specific SFNP programs throughout North America, such as Farm to School, little empirical evaluation research appears to have been conducted on the impact of these programs on dietary psychosocial and behavioural outcomes. Futhermore, research to date has shown that measures to evaluate dietary outcomes of these programs may sometimes be innappropriate (Taylor & Johnson, 2013). Research on SFNPS in British Columbia (BC), such as Farm to School and the BC School Fruit and Vegetable Nutritional Program (BCSFVNP), appears to show the potential for these programs to have a positive impact on student dietary psychosocial and behavioural outcomes. For example, in the BC report of Farm to School, participating schools provided information on meeting program objectives. The report concluded that student dietary intake of fresh fruits and vegetable and food variety had increased following the program (Bays, 2010). A vice principal at one elementary school stated that “Having salad bar in place 2 days per week heightened awareness of healthy eating habits and there was an increase in the demand and consumption of fresh fruits and vegetables on non- salad bar days at our cafeteria” (Bays, 2010, p. 10). The report also discussed that in order to properly establish whether the objectives of the program have been achieved there is a need to “Expand the evaluation component of the program to more closely explore: the impact o 51 [of] local and traditional foods in the salad bar on student eating behaviours; the impact of the program on participating farms and the local food economy; and the unique Farm to School Salad Bar models that are emerging in aboriginal, rural, and remote settings” (Bays, 2010, p. 16). In addition, in the Summary of the Michael Smith Foundation for Health Research evaluation of the Farm to School Salad Bar initiative, authors described that initial survey results from four schools propose that school salad bars lead to an increase in both the ease of consuming daily fruit and vegetables and willingness to try fruit and vegetables (Social Research and Demonstration Corporation, 2010). Furthermore, findings showed that student dietary intake of fruit and raw vegetables in addition to the occurrence of grating vegetables or consuming salad also increased (Social Research and Demonstration Corporation, 2010). Secondly, in the report of the BC School Fruit and Vegetable Nutritional Program, results from the surveys faxed by schools (n=51) revealed that 14 schools reported “Improved eating habits of students/changing attitudes” and “Students trying new foods”, and 13 schools reported “Increased school-wide and parental awareness of healthy eating” (Naylor & Bridgewater, 2007, p. 38). Initial results from these studies suggest the potential for the BC Farm to School Salad Bar initiative and the BCSFVNP to have a positive impact on student dietary psychosocial and behavioural outcomes. Nevertheless, there does not yet appear to be empirical and peer-reviewed research on these programs or other current SFNPs available in Vancouver or BC. Furthermore, in an article discussing current research on Farm to School programs and students outcomes, the article emphasized the need for future research to evaluate dietary intake using assessment measures that have been previously validated in order to properly establish whether programs are effective (Taylor & Johnson, 2013). The authors describe that literature to date is often conducted by individual programs themselves, and relies on measures such as student 52 self-report, participation rates in school lunches, and fruit and vegetable selection, to evaluate overall program effectiveness in promoting fruit and vegetable consumption among students (Taylor & Johnson, 2013). However, authors discuss that measures such as school lunch participation and fruit and vegetable selection may not accurately reflect intake. Furthermore authors stated that “Although children’s self-reports of fruit and vegetable intake may provide some insight into dietary behaviours, with the exception of two studies (Slusser et al. 2007; Center for HPDP 2011), most of the reports used methodologies that have not been validated against actual intake. Consequently, little concrete evidence is available to indicate the actual impact of FTS on children’s dietary intake.” (Taylor & Johnson, 2013, p. 74). Research and reports on current SFNPs available in Vancouver and North America, such as Farm to School, clearly indicate that little empirical evidence exists on program dietary psychosocial and behavioural outcomes, and that measures used to evaluate program outcomes may often be inappropriate. As a result, future research investigating outcomes of participation in SFNPs is needed in order to provide evidence demonstrating that the implementation of these programs are effective as initiatives to promote healthy and/or environmentally sustainable dietary psychosocial and behavioural outcomes among students. 1.4 Summary of Current Gaps in the Literature Investigating School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Psychosocial and Behavioural Outcomes To date, limited research has investigated participation in school food and nutrition programs (including whether differences in participation occur by gender or school type), healthy and environmentally sustainable dietary attitudes, expectations, dietary choices or food practices, among youth, and associations between participation in school food and nutrition programs and healthy and environmentally sustainable dietary psychosocial and behavioural among students. In 53 addition, few studies in these areas of research have evaluated outcomes specific to school days. Lastly, limited literature appears to exist in these areas of research among Vancouver children and adolescents. The following section describes the present gaps in these areas of research. 1.4.1 Participation in School Food and Nutrition Programs and Differences by Gender and School Type Though a few studies have investigated participation in SFNPs, there does not appear to be research specifically measuring student participation rates in the seven SFNP activity categories discussed, nor does there appear to be research evaluating participation among students in food or nutrition related school clubs or teaching cafeterias. In addition, no literature appears to have investigated which SFNP activity categories are reported most or least frequently among students, whether student participation rates in SFNP activity categories vary between schools, and whether participation rates between different SFNP activity categories are similar within schools. Though research investigating differences in student participation in food and nutrition activities between genders and school type or grade revealed possible significant differences in participation among these groups, no research appears to have specifically measured differences in the percentage of students participating between genders and school types. 1.4.2 Healthy and Environmentally Sustainable Dietary Attitudes and Expectations Although some research has been conducted on healthy and environmentally sustainable dietary attitudes and expectations among children and adolescents, little research has investigated attitudes related specifically to overall purchasing of dietary items on school days, reflecting options considered to be healthy, environmentally sustainable, or both. Furthermore, there is limited literature measuring attitudes towards caring about the impact of food choices on the environment or expectations related to the impact of general food choices on the environment among youth. 54 1.4.3 Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days Literature on school day dietary behaviours among children and/or adolescents appears to be limited, particularly in the case of dietary behaviours reflecting environmental sustainability. In addition, there appears to be little to no research specifically looking at student food practices on school days, such as breakfast and lunch consumption, frequency of purchasing at different types of convenience food establishments, and frequency of consuming foods grown in the neighbourhood/community (including school) or composting uneaten food at school. Furthermore, as previous studies investigating dietary intake among Vancouver youth have focussed on young children, such as the study by Mulder et al. (2011), which investigated sodium intake among ages 16 months to 6 years, there does not appear to be research evaluating dietary intake among older children and adolescents attending elementary or secondary school in the Vancouver student population. 1.4.4 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations Several gaps appear to exist in the literature evaluating associations between participation in SFNP activities and dietary attitudes and expectations related to health and/or environmental sustainability. Though some studies have shown the potential for participation in SFNPs to have a positive impact on healthy and environmentally sustainable dietary attitudes and expectations, research to date appears to have focussed on attitudes (non-specific to school days) related to health, and very few studies have investigated attitudes related to environmental sustainability. Additionally, there does not appear to literature investigating the associations between SFNPs and attitudes specifically related to the purchasing of dietary items on school days. Lastly, few studies appear to have been conducted evaluating the influence of school food and nutrition programs on 55 dietary attitudes or expectations supporting either environmental sustainability or both health and environmental sustainability, such as attitudes towards items that are locally produced or that have a low environmental impact through minimal packaging or processing, or expectations related to the environmental impact of dietary choices. 1.4.5 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days Though research to date has shown the potential for SFNPs to have a positive impact on student dietary behaviours, similar to the limited research assessing the associations between SFNPs and healthy and environmentally sustainable dietary attitudes and expectations, there also appear to be few studies investigating the associations between participation in SFNPs and healthy and environmentally sustainable school day dietary choices and food practices among youth. Furthermore, most studies investigating these associations appear to have focussed specifically on dietary intake of vegetables and/or fruit, as opposed to other categories of dietary choices, including less healthy options, such as sugar-sweetened beverages, or food practices, including breakfast consumption, eating nothing for lunch, and convenience food purchasing. In addition, limited research appears to have evaluated environmentally sustainable dietary choices or food practices, including the food practices of consuming foods grown within the neighbourhood/community (including school) and composting uneaten food at school. 1.5 Study Purpose and Objectives Due to the importance of encouraging healthy and environmentally sustainable dietary behaviours among children and adolescents (including specifically on school days), the possible influence of psychosocial factors on dietary choices and food practices among youth, and the potential role of school food and nutrition programs in promoting healthy and environmentally 56 sustainable outcomes among children and adolescents (particularly those specific to school days), research on participation in SFNPs, healthy and environmentally sustainable outcomes, and associations between participation and these outcomes, is clearly needed. However, despite current initiatives, recommendations, and evidence (including participation in SFNPs), encouraging healthy and environmentally sustainable dietary psychosocial and behavioural outcomes among children and adolescents, and the variety of SFNPs available throughout Vancouver, little is known about student participation rates in these programs, dietary psychosocial and behavioural outcomes related to health and/or environmental sustainability among Vancouver students (particularly those specific to school days), or whether participation in current SFNP programs available in Vancouver are associated with healthy and environmentally sustainable dietary psychosocial and behavioural student outcomes. As a result, the main purpose of this study was to examine whether participation in SFNPs among Vancouver students in grades 6-8 is associated with student healthy and environmentally sustainable dietary psychosocial and behavioural outcomes. Grade 6-8 students were chosen for this study due to the potential importance of adolescence in influencing long-term behaviours and long-term health (Story et al., 2002), and to allow for the comparison of students in elementary and secondary school who would be of a similar age range, but who would most likely have different school food environments and differences in their levels of autonomy in making decisions related to dietary choices and food practices, based on whether they attend elementary or secondary school. For example, in comparison to secondary schools in Vancouver, the majority of elementary schools do not provide food purchasing opportunities at school (such as vending machines or a cafeteria), many elementary schools offer a subsidized universal lunch program (VSB School Lunch Program), and in addition, many elementary schools 57 grant limited permission for students to leave the school grounds during school hours (personal communications with VSB staff and Think&EatGreen@School co-investigators, 2012). The specific research objectives for this study, investigating Vancouver students in grades 6-8, were: 1) to establish the proportion of students participating in different School Food and Nutrition Programs (SFNPs) among students at the student-level, as well as at the school-level (participation in activities between schools and participation between activities within schools), and whether participation in different SFNPs differs by gender or school type (elementary versus secondary), 2) to describe the healthy and environmentally sustainable dietary attitudes (including attitudes specific to school days) and expectations of students, 3) to describe the school day healthy and environmentally sustainable dietary choices and food practices of students, 4) to determine the associations between participation in different SFNPs and healthy or environmentally sustainable dietary attitudes or expectations among students (including attitudes specific to school days), and 5) to evaluate associations between participation in different SFNPs and school day healthy and/or environmentally sustainable dietary choices or food practices among students. 58 Chapter 2: Research Methods 2.1 Study Design The study involved a cross-sectional survey of students in grades 6-8 attending Vancouver public schools. Administration of a web-based questionnaire was conducted in classrooms of participating elementary and secondary schools (field setting) between March and June, 2012. Data was collected through the UBC “Food Practices on School Days” study, in collaboration with the Think&EatGreen@School Project research. The “Food Practices on School Days” study, currently being conducted through the UBC Food, Nutrition, and Health Program, is a study aiming to assess dietary intake, as well as diet-related knowledge, experiences and attitudes, among Vancouver elementary and secondary school students. 2.2 Questionnaire Development Two different web-based versions of the questionnaire were created through the revision process in developing the final questionnaire used in data collection. The initial version of the questionnaire was informed by a previously validated web-based questionnaire using a similar format (Hanning et al., 2009). The second and final version of the implemented questionnaire was developed using the Vovici (Vovici Corporation, 2013) EFM (Enterprise Feedback Management) Survey Tool available through UBC Information Technology (2013), contracted through Verint. EFM is Canadian-hosted and adheres to the BC Freedom of Information and Protection of Privacy Act (UBC Information Technology, 2013). Features of this questionnaire development tool included the ability to include pop-up messages within the survey (containing additional information to assist in answering questions), scroll down options, choose all that apply responses, questions with a space provided for typed responses, matrices for similar questions with identical responses, and the option 59 for users to skip questionnaire pages, return to previous pages, and/or change most responses if needed. Revisions were made to the questionnaire throughout pilot testing with students of similar age to the study population, and through feedback received from members affiliated with the study and/or Think&EatGreen@School. Pilot testing and additional feedback provided aimed to address the face and content validity of the questions, as well as the appropriateness of the questionnaire in terms of age and comprehension level. This first version of the questionnaire was pilot tested in the summer and fall of 2011 with 29 students. Pilot test participants included elementary and secondary school students of similar age or older to the study population from schools mainly in Vancouver, with a few additional schools from other locations in the lower mainland. Pilot tests were led by research assistants, and involved focus group sessions, following completion of the questionnaire. A standard set of focus group session questions was developed for the first version of the questionnaire to ask students for specific feedback regarding the questionnaire, and to allow students to make recommendations for improvements. The second version of the questionnaire was pilot tested in March of 2012. One grade 6/7 class of thirteen grade 7 students and fourteen grade 6 students was recruited to participate from one elementary school that was not included in our final study. The pilot questionnaire included general follow-up questions at the end of the questionnaire regarding participants’ overall impressions of the length of the survey and of the questions asked. Follow-up questions, addressing specific questionnaire questions which would benefit from feedback from participants in our study age group, were also included at the end of the survey. Short focus group sessions were held following 60 the survey session. The follow-up feedback questions included at the end of the questionnaire were used as a guide for the focus group discussions. A second pilot survey session was also conducted with the same class of students, one week after completion of the first survey. Focus group discussions were also held following the second survey sessions, using similar feedback questions to those used in the first survey session focus groups. The pilot test sessions were mainly conducted in order to provide an opportunity to assess face and content validity of the survey to determine if there were any questions that created confusion for students, and to ensure that the questions were worded clearly and were at an appropriate reading comprehension level for the study age group. The final questionnaire included a total of 121 questions (not including the first two questions, following the written survey introduction, pertaining to “user ID” and student assent), and incorporated questions measuring student characteristics, participation in SFNPs, and healthy and environmentally sustainable dietary psychosocial and behavioural outcomes. Student characteristics included demographics, such as school, grade, age, and gender, and additional factors that could potentially be associated with outcomes being evaluated. 2.2.1 Participation in School Food and Nutrition Programs In order to evaluate participation in school food and nutrition programs, a series of questions were developed to ask students whether they had participated in a list of possible school programs that would most likely pertain to food, nutrition, and/or environmental sustainability. As no validated questionnaires measuring participation in school food and nutrition programs available in the Vancouver School District appeared to exist at the time of this study, the list of programs and activities incorporated into the questionnaire were largely based on programs and activities currently implemented within the Vancouver School District, as previously described. The three main 61 categories of programs included in the questionnaire were SFNP activities, SFNP clubs, and teaching cafeterias. The specific SFNP activities included in the questionnaire represented activities from seven SFNP categories of interest. These activity categories were selected based on their potential association with healthy and/or environmentally sustainable dietary psychosocial and behavioural outcomes. The activity categories included: 1) Food preparation activities, such as learning how to cook; 2) Choosing or tasting healthy foods activities, including grocery shopping and tasting healthy foods; 3) Learning about Canada’s Food Guide; 4) Learning about foods grown in British Columbia; 5) Gardening activities, such as learning how to grow food in a garden; 6) Composting activities, including composting on my own (e.g. putting leftovers from lunch in a compost bin); and 7) Recycling activities, such as learning how to recycle. Response options provided were similar to those applied in the Student Survey included as part of the Farm to School Sample Tools and Resources for program evaluation published in the 2009 report “Bearing Fruit: Farm to School Program Evaluation Resources and Recommendations” from the Center for Food & Justice, Urban & Environmental Policy Institute, Occidental College. For example, in the Student Survey, students were asked in question 26, “Have you ever grown food in a garden?” (Joshi & Azuma, 2009, p. 149). A follow-up question was also used to ask students to select all locations where they had gardened. Options included “1) at home, 2) at school, 3) a friend’s house, 4) a relative’s house, 5) during an after school program, 6) during a summer program, 7) other: (please explain)” (Joshi & Azuma, 2009, p. 149). In the present study, students were asked to report whether they had participated this school year in any of the individual activities listed. Example questions and response options are shown in Figure 2-1. (For the complete set of individual activity questions please see Appendix A: q49 & 51). 62 Q: Have you participated in any of the following this school year (anytime since September)? Choose all that apply. No Yes - At school (or as part of a school activity) Yes - At home Yes - At someone else's home Yes - In my community Yes - In a summer program Yes - Other Learning how to cook Cooking on my own (e.g. making dinner at a friend's house) Learning how to grocery shop Grocery shopping on my own Choosing healthy foods Preparing healthy foods Tasting healthy foods Learning about Canada’s Food Guide Learning about what foods are grown in British Columbia Figure 2-1 – SFNP individual activity example questions Questions regarding participation in SFNP clubs were based on participation in any of the following clubs, listed in the questionnaire as “Environmental Club, Ecology Club, Cooking Club, Recycling Club, Composting Club, Gardening Club (growing food…)”. Students were asked to select either a response of “Yes - I have been a member of one of more of these clubs” or “No - I have never been a member of any of these clubs” with regard to the list of clubs included in the question. In addition, students were asked whether they had participated in any of the clubs listed this school year (anytime since September). Students were provided with the response options of “Yes - I have been a member of a club this school year” and “No - I have not been a member of a club this school year” with respect to the clubs listed (Appendix A: q57-58). 63 In terms of evaluating student participation in teaching cafeterias, after students indicated whether they had a teaching cafeteria at their school, students who selected “Yes” to having a teaching cafeteria were expected to have received a follow-up question asking students to select “Yes” or “No” to whether they had worked in the teaching cafeteria this year through the following question: “This year, have you ever worked in the teaching cafeteria?” (Appendix A: q67). Students who reported that they had participated were expected to have been provided with a follow-up question requesting students to select whether they had participated in each of four listed possible jobs in the teaching cafeteria, which included: preparing food, cleaning up during or after a meal, serving food, and collecting money from customers (Appendix A: q68). The question listing the possible teaching cafeteria jobs students may have participated in can be seen in Figure 2-2. Q: Which of the following have you done this year in the teaching cafeteria? Please choose all that apply. I have helped prepare food I have helped clean up during or after a meal I have helped serve food I have helped collect money from customers Figure 2-2 – Teaching cafeteria question set for specific jobs performed in the teaching cafeteria 2.2.2 Dietary Attitudes The main dietary attitude question set reflected attitudes towards food or beverage purchasing on school days. Attitudes towards school day food purchases were based on current recommendations for healthy and/or environmentally sustainable dietary choices. For example, the attitude towards the food including fresh vegetables was considered to represent a healthy attitude, as selecting vegetables prepared with little or no added salt, fat, or sugar, reflects current recommendations from Canada’s Food Guide (Health Canada, 2007a). Questions were similar to 64 those applied by authors in the study by Gosliner et al. (2011), evaluating the importance of purchasing specific food items at school. Examples of questions from the question set and response options can be seen in Figure 2-3. Q: If you were to buy food or beverages on school days (either during school hours or on your way to or from school), how important would it be to you that… Not at all important Not very important Somewhat important Very important The food includes fresh vegetables The food is healthy Figure 2-3 – Dietary attitude example questions Attitudes towards food or beverage purchasing on school days included healthy, environmentally sustainable, and both health and environmental sustainability attitudes. The healthy dietary attitude questions asked about the importance that “The food includes fresh vegetables” and that “The food is healthy” (Appendix A: q39). Environmentally sustainable dietary attitudes included that “The food is local (food that is grown or produced locally e.g. from a community garden, farm, or farmers market)” and that “The food is environmentally friendly (e.g. grown, processed and/or packaged in ways that have the smallest negative impact on the environment)” (Appendix A: q40-41). Lastly, two dietary related purchasing attitudes were considered to reflect both health and environmental sustainability. These attitudes included the importance of the food being “fresh rather than packaged” and the attitude of the food being “minimally processed” (Appendix A: q40-41). An additional environmentally sustainable dietary attitude question was also included, which asked students about their attitude towards caring about the impact of food choices on the 65 environment (Appendix A: q123). The question was framed similarly to those used in the development of the Project EAT questionnaire (Larson, Neumark-Sztainer, Story, & Burgess-Champoux, 2010; Neumark-Sztainer et al., 2007; Neumark-Sztainer et al., 2006). The question from the question set and response options can be seen in Figure 2-4. Q: How much do you care about…. Not at all A little bit Somewhat Very much How food choices impact the environment Figure 2-4 – Environmentally sustainable dietary attitude question related to caring 2.2.3 Dietary Expectations Two questions were included in the questionnaire to evaluate healthy and environmentally sustainable dietary expectations. Questions regarding dietary expectations incorporated in the questionnaire were phrased similarly to those used in the Project EAT questionnaire (Larson et al., 2010; Neumark-Sztainer et al., 2007; Neumark-Sztainer et al., 2006). Evaluation of healthy dietary expectations was addressed by asking students whether they agreed that food choices affect their health (Appendix A: q122). Examples of questions from the question set and response options can be seen in Figure 2-5. Evaluation of environmentally sustainable expectations was measured similarly to healthy expectations by asking students whether they agreed with the expectation that food choices affect “The environment” (Appendix A: q122). 66 Q: How strongly do you agree with the following statements? The types of food I eat affects: Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree My health The environment Figure 2-5 – Dietary expectations example questions 2.2.4 Dietary Choices A detailed non-quantitative food frequency questionnaire (FFQ) was developed for the measurement of student dietary intake. The rationale for the choice of the FFQ was based on the consideration that an FFQ would provide the best measure of dietary intake to address the study objective involving the evaluation of usual intake of dietary choices among students on school days. For example, though a 24-hour recall could have been incorporated into the questionnaire to assess dietary intake, the use of one 24-hour recall rarely represents usual intake of an individual (Lee & Nieman, 2007). In addition, due to the length of time required for students to accurately complete a 24-hour recall, the use of an FFQ would reduce the amount of time needed to complete the dietary intake portion of the questionnaire, and would therefore allow the inclusion of additional diet-related questions that were of importance to this study. After reviewing the current body of literature, no validated food frequency questionnaires assessing school day intake of healthy or environmentally sustainable dietary choices appeared to have been established. Therefore, the majority of questions included in the survey were adapted from previously validated questionnaires. In the survey, the statement “Hold the arrow over the food to learn more about the food or serving sizes” was included as a prompt to inform students of a design feature of the survey which allowed the survey to provide pop-up messages with additional information when a computer mouse cursor was held over survey words that had been underlined. For example, pop-up messages for 67 specific FFQ items provided examples of the item or typical serving sizes of the item, to assist students in estimating the frequency of intake of each food or beverage item listed. The FFQ measuring healthy and less healthy dietary choices was developed based on questions adapted from previously validated questionnaires used in similar study populations (Appendix A: q10-12, 16-18). These questionnaires include the SHAPES Youth Healthy Eating Survey School Health Action, Planning and Evaluation System, 2008) and the Florida Youth Survey 2003 (Park, 2003; Park, Sappenfield, Huang, Sherry, & Bensyl, 2010). Questions were also modified to include food group items from Canada’s Food Guide (Health Canada, 2007a) and additional items specific to the Vancouver School Board student population. The reference period chosen for the FFQ was the past 30 days. This reference period was selected, as it was believed to provide a reasonable time period in order to estimate typical intake of dietary choices. The frequency scale chosen for the FFQ and most food practices was similar to scales used in previous FFQ validation studies, which provided options for monthly, weekly and daily intake, such as a study by Slater, Philippi, Fisberg, & Latorre (2003). FFQ questions were framed by asking students to reflect on their average dietary intake “on school days (either during school hours or on your way to or from school)” over the past 30 days (Appendix A: q10-12, 16-18). Examples of questions from the question set and response options can be found below in Figure 2-6. The questionnaire question set in the figure can be found in Appendix A: q18. Healthy and less healthy dietary choices measured reflected recommendations from Canada’s Food Guide and the BC Guidelines. Some dietary choices also represented goal outcome indicators of school food and nutrition programs offered, as previously introduced. Healthy dietary choices included food and beverage options such as fruits and vegetables, whole grains, low-fat 68 milk or soy beverages, and water, whereas less healthy options included items such as sugar-sweetened beverages. Q: Snack Foods and Desserts: Looking back on the past 30 days, on average, how often did you eat the following on school days (either during school hours or on your way to or from school)? Hold the arrow over the food to learn more about the food or serving sizes. Never Once a month or less 2-3 times a month Once a week 2-4 times a week Once a day 2 or more times a day Salty packaged snacks Candy or chocolate bars Baked sweets Frozen desserts Figure 2-6 – Food frequency questionnaire example question set for dietary choice categories (question set for less healthy dietary choice category of Snack foods) A separate set of questions in the FFQ included specific questions relating to environmentally sustainable dietary choices (Appendix A: q22-23). Environmentally Sustainable dietary choices measured reflected recommendations of several Canadian and U.S. environmental sustainability initiatives previously described, aiming to reduce the impact of dietary choices on the environment, including items that are locally produced or items that are packaged in compostable packaging. In comparison to healthy dietary choice FFQ questions, the FFQ questions listing environmentally sustainable dietary choices were framed by asking students to reflect on their average dietary intake on school days “either during school hours or on your way to or from school” over the past year. The decision to provide a longer period of recall for the environmentally sustainable question sets was based on the expectation that intake of environmentally sustainable 69 items would most likely be less frequent than items included in Canada’s Food Guide, as food group items from Canada’s Food Guide were perceived to be more likely included as daily dietary choices. The first set of FFQ items reflecting environmentally sustainable dietary choices represented locally produced foods, and incorporated the following five items: “Local food (food that is grown or produced locally e.g. from a community garden, farm, or farmers market)”, “Food that was purchased at a local farmers market”, “Food bought directly from a farm”, “Food grown at a school (e.g. in a garden, in balcony planters, or in an orchard or greenhouse)”, and “Food grown by someone you know (e.g. at home, in the community, etc.)”. Response options for the first set of questions ranged from “Never” to “2 or more times a week” on a 5 point scale. “I don’t know” was also included as a response option (Appendix A: q22). Example questions from the first set of the environmentally sustainable food frequency questionnaire items can be found in Figure 2-7. Q: The following question asks you about eating specific categories of foods. Looking back on the past YEAR, on average, how often did you eat the following on school days (either during school hours or on your way to or from school)? Never Once a month or less 2-3 times a month 1 time a week 2 or more times a week I don’t know Food that was purchased at a local farmers market Food bought directly from a farm Food grown at a school (e.g. in a garden, in balcony planters, or in an orchard or greenhouse) Figure 2-7 – Food frequency questionnaire example questions from the first set of environmentally sustainable dietary choice item questions 70 The second set of FFQ items reflecting environmentally sustainable dietary choices included two additional local items, “Food that you helped grow” and “Food from a Community Supported Agriculture (CSA) program”, as well as two items reflecting environmentally sustainable packaging, “Food or beverages in recyclable packaging (instead of packaging that goes in the garbage)” and “Food or beverages in compostable packaging that can be composted (instead of packaging that goes in the garbage)”. Response options for the second set of questions ranged from “Never” to “2 or more times a day” on a 7 point scale, and included an eighth option of “I don’t know” (Appendix A: q23). Example questions from the second set of the environmentally sustainable food frequency questionnaire items can be seen in Figure 2-8. Q: Looking back on the past YEAR, on average, how often did you eat the following on school days (either during school hours or on your way to or from school)? Never Once a month or less 2-3 times a month 1 time a week 2 or more times a week 1 time a day 2 or more times a day I don't know Food that you helped grow Food or beverages in recyclable packaging (instead of packaging that goes in the garbage) Food or beverages in compostable packaging that can be composted (instead of packaging that goes in the garbage) Figure 2-8 – Food frequency questionnaire example questions from the second set of environmentally sustainable dietary choice item questions Additional FFQ items were also included to measure frequency on intake of dietary choices considered either less environmentally sustainable or both less healthy and less environmentally sustainable. The dietary choice item bottled water was incorporated in the questionnaire to reflect a 71 less environmentally sustainable dietary choice (Appendix A: q11). A set of FFQ questions including snack food type items, that may contain additional salt, sugar, and/or fat, and/or those that may be highly processed or packaged, was included to represent items considered both less healthy and less environmentally sustainable dietary choices (Appendix A: q18). 2.2.5 Food Practices Questions describing healthy or less healthy food practices were adapted from previously validated questionnaires, including the SHAPES Youth Healthy Eating Survey (School Health Action, Planning and Evaluation System, 2008) and the Florida Youth Survey 2003 (Park, 2003; Park, et al., 2010). The one question reflecting healthy food practices related to the consumption of breakfast. Consumption of breakfast was chosen to represent a healthy food practice, due to the previously described benefits of consuming breakfast among children and adolescents (Shaw, 1998). The question and response options are shown below in Figure 2-9 (Appendix A: q33). The questionnaire also included the less healthy food practice of not eating anything for lunch (Appendix A: q30). Figure 2-10 lists the question and response options. In addition, as part of evaluating less healthy food practices among students, participants were also asked to report on the frequency of purchasing items from the following convenience food establishments: “Fast food or take out restaurant or food court”, “Convenience Store”, or “Coffee Shop” (Appendix A: q24). The question and response options can be seen in Figure 2-11. 72 Q: In a typical month, on Monday through Friday (anytime of the day), how often do you... Never Once a month or less 2-3 times a month Once a week 2-4 times a week Once a day Eat breakfast Figure 2-9 – Breakfast intake question and response options Q: In a typical month, how often do you do each of the following on school days (either during school hours or on your way to or from school)? Never Once a month or less 2-3 times a month Once a week 2-4 times a week Every school day Eat nothing for lunch Figure 2-10 – Lunch intake question and response options Q: In a typical month, how often do you drink or eat food that you purchased at the following places on school days (either during school hours or on your way to or from school)? Never Once a month or less 2-3 times a month Once a week 2-4 times a week Once a day 2 or more times a day Fast food or take out restaurant or food court Convenience store (such as 7-Eleven) Coffee shop Figure 2-11 – Purchasing at convenience food establishments questions Environmentally sustainable food practices measured reflected recommendations of several Canadian and U.S. environmental sustainability initiatives, as previously discussed, aiming to promote environmental sustainability through practices such as composting. Students were asked 73 how often they engage in environmentally sustainable practices in a typical month (Appendix A: q30). Response options were identical to those provided for the less healthy food practice item question Eat nothing for lunch. The included questions asked students specifically about the frequency of their consumption of “Food grown at school, at home or in your community (for example in a garden, in balcony planters, or in an orchard or greenhouse)” and how often they “Put leftover food that you didn’t finish eating into a compost bin at school”. Consistent with those applied for the less healthy food practice Eat nothing for lunch, response options included “Never” to “Every school day”. 2.3 Data Collection In order to conduct data collection, a study protocol was first developed in addition to a survey guide, a field notes form, and a student handout for use during survey sessions. The detailed study protocol was written to describe the steps required for participant recruitment and follow-up, as well as survey administration. The survey guide was also developed to be used when conducting each session. The standard field notes form was also created for collecting field notes from the survey session and for gathering classroom information, including the number of students participating and the number absent (Appendix B). Lastly, the standard student handout was developed which included the website link to the survey, instructions on how to begin the survey, a space to record contact information if students were interested in participating in a similar study in the future, and a unique student user ID. The reverse of the handout contained a list of alternative web-based nutrition related activities for students. Once students had completed the questionnaire, students were given the option to try the web-based activities or an activity selected by the class teacher. Students who did not participate, or who chose to stop the survey before completion, were 74 also given the opportunity to participate in the alternative web-based nutrition related activities or a teacher chosen activity. The student user ID assigned a four letter code, which identified the school and class session to which the student belonged, in addition to a unique two digit number, which established the specific student participant in the class. The student user ID could therefore be used to determine the number of students who participated in each class at each school, and to ensure that there were not multiple survey submissions from one class with the same ID two digit number. To ensure a sense of equality and inclusion in the research process, all students in each invited class were given the opportunity to participate, with the exception of students who had not been granted parent/guardian passive consent or for whom the teacher had requested that they not participate due to reasons including inadequate reading comprehension level and/or physical, mental, or behavioural abilities needed to complete a web-based survey. Students not receiving parent/guardian passive consent consisted of students who had not provided the form to their parent/guardian or who believed that their parent/guardian had not seen the form, in addition to students whose parent/guardian had signed the form requesting the student not participate. 2.3.1 Participants Though the study was initially designed to compare grade 7 and 8 students, many schools within the VSB have classes combining grade 6 and 7 students. As grade 6 students in combined classes with grade 7 students were anticipated to have similar opportunities and experiences to the grade 7 students in their classes, grade 6 students from the combined classes who participated in the questionnaire were included in the study. In a few participating VSB classes, more than two grades were combined into one class, such as grades 5, 6, and 7. However, as the focus of this study was to 75 compare elementary school and secondary school students of similar age, and it was uncommon for grade 5 students to be in a class with grade 7 students, grade 5 was not included in the study inclusion criteria. Therefore, the study applied the following inclusion criteria for participation: 1) students in grade 6-8 in Vancouver public schools, and 2) students providing individual assent and who have received passive parental consent. As a result, data collected from grade 5 students in combined classes were not included in analyses. Consent for participation was obtained through the use of a parent/guardian passive consent form, as well as a web-based student assent form. The student assent form was included as part of the online introduction to the survey. Following the assent form, students were asked whether they wished to participate in the survey (Appendix A: q2). Students who chose not to respond to this question or who selected “no” as a response were not able to proceed with the survey. This study was approved by both the University of British Columbia and the Vancouver School Board. Ethics approval was received from the University of British Columbia Behavioural Research Ethics Board (BREB). In addition, the Vancouver School Board (VSB) provided approval for the study to be conducted in the Vancouver School District. 2.3.2 Sampling and Recruitment Schools were primarily selected using purposive sampling. Initial sampling efforts involved inviting schools that had a previous or current connection to Think&EatGreen@School (e.g. schools who had received small grants from the project or schools who had participated in project activities) in order to collect data from schools involved in the project. In addition, to reflect the geographic and demographic variability in the Vancouver student population, additional recruitment efforts were based on ensuring a selection of schools from all sectors of the VSB, and/or ensuring schools 76 in Vancouver perceived to have students with distinct demographic and social characteristics, were represented in the sample. Overall, the schools recruited for this study included schools with both dense and sparse neighbourhood food retail environments, in addition to schools with students from various communities within the Vancouver school system and with a wide-range of ethnic and socio-economic backgrounds. Recruitment was carried out by research assistants. In the initial stages of contacting individual schools, a request for participation and a study approval letter from VSB was sent by email to VSB school principals. In addition, a list of all grade 7 teachers, and a list of grade 8 teachers teaching specific required subjects, was requested for recruitment purposes from each school. Research assistants were responsible for contacting eligible teachers from each school. In elementary schools, grade 7 teachers were contacted in no set order, as all students were believed to have a relatively equal probability of being included in any grade 7 classroom at the school. However, in secondary schools, participation was requested from teachers teaching grade 8 subjects known to be typically required as part of the curriculum in the Vancouver public school system. Required subjects were chosen to reduce sampling bias by ensuring a comparatively equal opportunity for participation among grade 8 students from the school population at each school. The subjects chosen included: home economics, physical education, and/or health and career development. These required subjects were selected as they were expected to involve education on health and/or nutrition. Inviting classes teaching subjects pertaining to health and/or nutrition was thought to have the potential to increase the number of teachers interested in participating, as the study was anticipated to have more relevance to the class course curriculum of these subjects compared to other subjects, such as mathematics. Therefore, to ensure consistency when contacting teachers in secondary schools, teachers were contacted in the order of home economics, health and career development, or physical education, based on which of these 77 subjects they taught. Previously established connections between research assistants and teachers or Think&EatGreen@School community partners also helped in contacting and recruiting additional teachers from interested schools. In one case, an email regarding interest in study participation was received from a teacher at one school teaching grades 5-6. As research team members did not have reason to believe that Gr. 6 students in this particular class would differ from other Gr. 6 students at the school, this class was granted permission to participate. Invitations were issued based on teachers’ availability to respond to the request at the time the teacher or school was contacted. When contacted by phone, email, or in-person, teachers were typically provided with a brief overview of the study, as well as the steps required to participate. When possible, a potential date and class period in which to deliver the questionnaire was established. For teachers interested in participating, a follow-up letter was normally provided with additional study details, including the anticipated benefits of the study for both teachers and students. Parent/guardian passive consent forms were provided to participating teachers approximately 1-2 weeks prior to the survey session through email, mail, or hand delivery. Teachers were responsible in most cases for administering passive consent forms to students, and collecting any signed forms from students prior to the survey. Included as part of the study protocol, a research team member often contacted teachers to provide a reminder of the importance of distributing the forms to students, as well as the importance of collecting forms from students, prior to the survey session. As a thank you for volunteering to participate, teachers were also offered a gift certificate from either of two bookstores or a school supplies retailer. 2.3.3 Questionnaire Administration Administration of the online questionnaire was conducted by research assistants, most of who had also been involved in initial recruitment efforts. To ensure consistency in administering 78 class survey sessions, research assistants followed a standard protocol and survey session guide when preparing for and conducting the surveys. All research assistants assisting with survey sessions were asked to review the study protocol, guide, and survey session forms, prior to the session. In addition, research team members leading the sessions frequently reviewed the protocol and guide with research assistants aiding with the sessions. Each survey session was approximately 80 minutes in length, including a short verbal introduction and closing remarks. The questionnaire was completed by students on school computers, typically located in the school’s library or computer lab. In some schools, computers and/or portable laptops were available to be used by students in their individual classrooms. As per the study protocol, at the beginning of each survey session, a standard verbal introduction to the survey and a review of consent and confidentiality was provided to students by research assistants. Participants were informed of the purpose of the study, and instructions were reviewed from the handout provided on how to access the survey website and enter their user ID. Students were also informed of the electronic pop-up messages included in specific questions to assist participants in understanding the question or response options provided. Students were reminded that their responses would be confidential and that they could end their participation in the study at any time. Furthermore, students were asked not to share responses or discuss the questionnaire with others until all students in the class had completed and submitted the survey. Students were also asked to direct all questions to research assistants during the survey session. At least one research assistant was present at the school throughout survey sessions. 2.4 Analytic Sample From the 26 VSB schools that took part in this study, a total of 1,229 students were enrolled in the participating classes. In two circumstances, the grade 7 students of a second class in the 79 school were added to the students in the participating class. In these two cases, the total number of students eligible to participate in the survey session was calculated based on the number of eligible students in the participating class in addition to the number of grade 7 students enrolled in the second class. From the students who participated in the survey sessions, a total of 964 surveys were successfully submitted. As the FFQ only evaluated school day intake, it was not possible to establish whether intake reported appeared plausible in terms of an estimate of daily intake, as reported intake did not reflect intake over the entire day. For example, students who reported never or rarely consuming specific FFQ items at school may often consume these items before or after school. Due to these established limitations, no students were removed from analysis due to perceived implausible dietary intake. Following the review of submitted surveys, 937 student surveys were included in the final study sample, resulting in a participation rate of 77.5% (1,209 students initially eligible to participate). Figure 2-12 shows a flow diagram of the steps taken in the removal of students from the initial sample in order to generate the final sample of student participants included in analyses. Appendix C provides a detailed description of the process in removing students from the final analyses as shown in Figure 2-12.80 Figure 2-12 – Selection of final student surveys included in analyses 1,229 Students (26 Schools) - 20 Elementary schools - 6 Secondary schools 1,209 Students (eligible to participate) 20 Gr. 5 Students (inclusion criteria not met ) 54 Students (absent) 1,155 Students (present) (present) 189 Students (did not participate) - 141 (inclusion criteria not met) - 9 teacher request - 39 other 966 Students = 964 surveys (successfully submitted) 937 surveys (included in analysis) 27 surveys (removed) - 16 (inclusion criteria not met for assent) - 11 (inappropriate responses) (included in analysis) 81 2.5 Final Measures and Coding 2.5.1 Participant Characteristics Most demographic questions, including school, grade, age, and gender were composed of either scroll down response options or a list of responses from which to select. The majority of variables were therefore coded as “Yes” or “No” to each response option provided. However, though school was determined by the school selected from the scroll down list of all schools located in the Vancouver school district, student user IDs were also used to confirm the correct school for students who did not respond to the question or who chose a school that was not consistent with their ID. 2.5.2 School Food and Nutrition Program Activities Participation in each individual activity at school was created by coding “Yes” to the selection of “Yes - At school (or as part of a school activity)” for the activity. The remaining response options including “No” or the selection of participation in the activity outside of school, such as “Yes - In my community”, were coded as “No”. As the question type was “choose all that apply” and allowed students to choose all response options, students who responded “No” to the question but who also selected “Yes” to either participation in school or to participation in a setting outside of school, were coded as inconsistent. Individual activities were categorized as either related to health, environmental sustainability, or both health and environmental sustainability, due to their expected associations with dietary psychosocial and behavioural outcomes based on the discussion in the introduction regarding current programs available and previous literature investigating SFNPs. The SFNP healthy activities included: 1) Learning how to cook, 2) Cooking on my own, 3) Learning how to grocery shop , 4) Grocery shopping on my own, 5) Choosing healthy foods, 6) Preparing healthy 82 foods, 7) Tasting healthy foods, and 8) Learning about Canada’s Food Guide. The following activities represented the SFNP environmentally sustainable activities: 1) Learning how to make compost, 2) Composting on my own, 3) Learning how to recycle, and 4) Recycling on my own. Lastly, the three activities representing both health and environmental sustainability included: 1) Learning about foods grown in British Columbia, 2) Learning how to grow food in a garden, and 3) Growing food in a garden on my own. Additional details to explain the categorization of SFNP activity variables used in bivariate analyses will be described in the discussion of the approach to data analysis. Additional activity category variables were developed based on the overall categories of food and nutrition-related activities that students may be exposed to in the school setting which may be associated with dietary psychosocial and behavioural outcomes of interest. Categories were created by combining several individual activities that related to the SFNP exposure of interest. Similar to individual activities, categories were coded as “Yes” to participation at school versus “No” to participation at school. Coding of “Yes” to the category was based on the selection of one or more of the individual activities included in the category, and “No” reflected a selection of “No” to all individual activities within the category. For example, the Food preparation activities category was created by combining the individual activities that pertained to working with food, which included: “Learning how to cook”, “Cooking on my own”, and “Preparing healthy foods”. Activity categories were coded as inconsistent (comparable to individual activities) when an inconsistent response was provided to all individual activities included in the category. Activity categories were categorized as either related to health, environmental sustainability, or both health and environmental sustainability, based on the categorization applied to the individual activities within the category. Healthy activity categories included two activities: Food preparation 83 activities and Choosing or tasting healthy foods activities. The following two activities represented the environmentally sustainable activity categories: Composting activities and Recycling activities. The one both healthy and environmentally sustainable activity category was represented by Gardening activities. Table 2-1 describes the individual activities that were combined to generate activity categories, as well as the categorization of the activity category as either relating to health, environmental sustainability, or both. A list of SFNP activity variables applied in this study is presented in Table 2-2. Table 2-1 – SFNP individual activities combined in creating final activity categories Activity Category Individual activities included in each activity category Healthy Activity Categories Food preparation activities Learning how to cook Cooking on my own (e.g. making dinner at a friend's house) Preparing healthy foods Choosing or tasting healthy foods activities Choosing healthy foods Tasting healthy foods Learning how to grocery shop Grocery shopping on my own Environmentally Sustainable Activity Categories Composting activities Learning how to make compost Composting on my own (e.g. putting my leftovers from lunch in a compost bin) Recycling activities Learning how to recycle Recycling on my own (e.g putting my recyclables in a recycle bin) Both Healthy and Environmentally Sustainable Activity Category Gardening activities Learning how to grow food in a garden Growing food in a garden on my own (e.g. gardening at home) 84 Table 2-2 – School food and nutrition program variables School Food and Nutrition Program Activity Variables Individual SFNP Activities Learning how to cook Cooking on my own Learning how to grocery shop Grocery shopping on my own Choosing healthy foods Preparing healthy foods Tasting healthy foods Learning about Canada’s Food Guide Learning about foods grown in British Columbia Learning how to grow food in a garden Growing food in a garden on my own Learning how to make compost Composting on my own Learning how to recycle Recycling on my own SFNP Activity Categories Food preparation activities Choosing or tasting healthy foods activities Gardening activities Composting activities Recycling activities 2.5.3 SFNP Clubs and Teaching Cafeterias Participation in a school club or a teaching cafeteria was coded as “Yes” or “No” to participation at school from the answers provided to the “Yes” or “No” style questionnaire response options. Participation in each teaching cafeteria job was also coded as “Yes” or “No” based on whether the job was selected among the list of jobs provided in the question. 2.5.4 Dietary Psychosocial and Behavioural Outcome Variables For all outcome variables, responses were dichotomized based on the outcome response of importance and the proportion of students who responded to each response category in each 85 question likert scale. The dichotomization of response options has been applied in previous research evaluating dietary outcomes (Gosliner et al., 2011; Evans & Weisman, 2010). A list summarizing all dietary outcome variables applied in this study, including dietary attitudes and expectations, dietary choices, and food practice variables, can be found in Table 2-3. Please see footnote a in the table describing which variables were not applied in bivariate analyses with SFNPs. Table 2-3 – Dietary psychosocial and behavioural outcome variables Outcome Dietary Attitudes Healthy Dietary Attitudes Food Purchasing - Importance of Food Type b Importance fresh vegetables Importance healthy Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance local Importance environmentally friendly Food Choices - Caring about impact c Food choices - care very much impact on environment Both Healthy and Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vs. packaged Importance minimally processed Dietary Expectations d Healthy Dietary Expectation Food choices - agree affect health Environmentally Sustainable Dietary Expectation Food choices - agree affect environment 86 Outcome Dietary Choices Healthy Dietary Choice Items and Categories Vegetables Fruit Vegetables or fruit Whole grains Low-fat milk or soy beverages Water Less Healthy Dietary Choice Categories Sugar-sweetened beverages Energy dense entrees or side dishes Environmentally Sustainable Dietary Choice Items and Categories (weekly) g Local food a Food that was purchased at a local farmers market a Food bought directly from a farm a Food grown at a school (ever) e, g Food grown by someone you know a Food that you helped grow (ever) e Food or beverages in recyclable packaging a Food or beverages in compostable packaging a Food from a Community Supported Agriculture (CSA) program a Locally produced food Food or beverages in recyclable or compostable packaging Less Environmentally Sustainable Dietary Choice Items Bottled water Both Less Healthy and Less Environmentally Sustainable Dietary Choice Categories Snack foods 87 Outcome Food Practices Healthy Food Practices Eat breakfast Less Healthy Food Practice Items and Category (weekly) Eat nothing for lunch Fast food/takeout establishment purchasing a Convenience store purchasing a Coffee shop purchasing a Convenience food establishment purchasing Environmentally Sustainable Food Practice Items (weekly) Eat food grown in neighbourhood/community (including school) (ever) e Compost uneaten food at school f a Variables were not included in bivariate analyses with SFNPs. b Response options for purchasing attitudes dichotomized as "Not at all important"/ "Not very important" compared to "Somewhat important"/ "Very important" c Response options for caring attitude dichotomized as "Not at all " / "A little bit" / "Somewhat" compared to "Very much" d Response options for expectations dichotomized as "Strongly disagree" / "Disagree" / "Neither agree nor disagree” compared to "Agree"/ "Strongly agree" e Variables only tested with the activity category Gardening activities f Variable only tested with the activity category Composting activities g Unless specified by “(weekly)” or “(ever)” all dietary choice and food practice outcomes refer to "Daily" intake “Daily” refers to intake of ≥ once per day of an item for individual variables or a total intake of ≥ once per day of any combination of items within a category for category variables “(weekly)” refers to intake of ≥ once per week of an item for individual variables or intake of ≥ 1 item within a category ≥ once per week for category variables “(ever)” refers to any reported intake > never of an item for individual variables. (Each variable labelled “(ever)” consisted of an individual item. This item was also used to create a separate variable dichotomized as weekly. However, variables dichotomized as"(ever)" were the variables applied in bivariate analyses). 88 2.5.4.1 Dietary Attitudes For the attitude question set related to food purchasing, the response of interest was whether or not students felt item type was important or not towards food purchasing. As a result, from response options provided on a 4 point scale from “Not at all important” to “Very important”, responses were dichotomized into the two categories “Not important” versus “Important”. The two categories were created by grouping the responses “Not at all important” and “Not very important” into the category of “Not important”, and combining the remaining responses of “Somewhat important” and “Very important” into the category of “Important”. This approach to dichotomizing attitude questions has been applied in previous studies. For example, in the study by Gosliner et al. (2011) evaluating dietary attitudes towards the school food environment, for the attitude question “How important is it to you to be able to buy the following food items at school?”, authors dichotomized response options of the 4-point likert scale by combining participant responses of “important” with “very important” and by combining responses of “not too important” with “not at all important”. The final dietary attitude variables regarding food or beverages purchasing on school days included healthy, environmentally sustainable and both healthy and environmentally sustainable attitudes. Healthy attitudes were represented by Importance fresh vegetables and Importance healthy when purchasing food or beverages on school days. Environmentally sustainable attitudes were the Importance local and Importance environmentally friendly with regard to food or beverage purchases. Lastly, the two purchasing attitudes reflecting both health and environmental sustainability included: Importance fresh vs. packaged and Importance minimally processed. 89 The additional environmentally sustainable dietary attitude regarding how much students care about the impact of dietary choices on the environment, Food choices - care very much impact on environment, was dichotomized as caring “Very much” versus “Not very much”. The response category of “Very much” was the response category of interest as the response of whether students reported caring significantly about the impact of food choices on the environment was considered to be important. Therefore, from the 4 point scale from “Not at all” to “Very much”, the response category “Not very much” was created by collapsing the response options “Not at all” “A little bit” “Somewhat” and leaving the remaining response option “Very much” to represent the category “Very much”. 2.5.4.2 Dietary Expectations The two dietary expectation variables created included healthy and environmentally sustainable expectations related to the affect of food choices on either health or the environment. The healthy expectation included Food choices - agree affect health, and the environmentally sustainable expectation included Food choices - agree affect environment. Responses to the question set reflecting dietary expectations were dichotomized based on the category of interest and the distribution of student responses, using a similar approach to the coding of dietary attitudes. From the response options on a 5 point scale from “Strongly disagree” to “Strongly agree”, the response of interest was agreement with the statement versus lack of agreement. As a result, responses were dichotomized into the categories “Agree” versus “Disagree or neither” by combining the response options “Agree” and “Strongly agree” into the category “Agree”, and collapsing the remaining options of “Strongly disagree”, “Disagree”, and “Neither agree nor disagree”, into the category of “Disagree or neither”. 90 2.5.4.3 Dietary Choices Healthy and less healthy dietary choice categories were created by combining FFQ related food and beverage items that represented current Canada’s Food Guide recommendations and the BC Guidelines. For example Eating Well with Canada’s Food Guide recommends Canadians “Drink skim, 1% or 2% milk each day” and to “Drink fortified soy beverages if you do not drink milk” (Health Canada, 2007a). As a result, the category “Low-fat milk or soy beverages” was generated by combining the items “1% or skim milk”, “2% milk” and “Soy milk (plain)”. The final healthy dietary choices were represented by the following items and categories: Vegetables, Fruit, Vegetables or fruit, Whole grains, Low fat milk or soy beverages, and Water. The less healthy choices included the following two categories: Sugar-sweetened beverages and Energy dense entrees or side dishes. A list of the dietary choice categories applied in bivariate analyses, and details of which questionnaire items were combined in generating each category for dietary choice category variables, is provided in Appendix D. Please see the appendix table footnote denoted by “Note”, for the individual dietary choice items included in bivariate analyses. Each dietary choice item and category was dichotomized as “Daily” intake (5 school days per week, or every school day) versus “Less than daily” intake (< 5 school days per week) from the response options provided on a 7 point scale from “Never” to “2 or more times a day”. Daily intake was chosen as the outcome of interest, as it was considered to represent the frequency that may be important in having an impact on student health. In order to establish daily intake of items within a category, response options for each FFQ item were first assigned a value equivalent to the number of days per month indicated by the response. “Daily” intake was based on reported frequency of intake of any one individual item, or combination of items within a category, that totaled an intake of at least once per day, equal to a frequency sum of 20 school days per month (5 school days per 91 week or every school day in a typical month). The remaining frequency responses for individual items or items within a category equal to a sum of less than once per day were subsequently grouped into “Less than daily”. For response options that provided a frequency range, such as “2-4 times a week”, the lowest value was used within the range when calculating the sum of frequencies of intake of one or more items. The lowest value in the range was chosen to ensure a conservative approach was applied towards calculating the sum of days reported per month, as it was not possible to determine whether true reported frequency of consumption was at the upper or lower end of the range of the response option selected. For example, for a dietary choice category with three items, the sum of two items consumed “2-4 times a week” and one item consumed “Once a week” would have equaled a minimum of 5 days a week (or “Daily” consumption on school days) based on the combination of frequencies of intake of these items within the category using the lower value of the frequency ranges. However, for a category with two items, where one item was consumed “Once a week” and the second item was consumed “2-4 times a week”, the sum of frequencies of these items in the category would have been equal to 3 days of intake a week (based on the lower values of the frequency ranges), and would therefore have been categorized as “Less than daily” intake (< 5 days per week). The same reasoning and approach applied towards generating healthy and less healthy dietary choice categories was also applied in creating and dichotomizing the one dietary choice category considered to represent both less healthy and less environmentally sustainable dietary choices, Snack foods, into “Daily” versus “Less than daily”. The approach used in this study towards generating dietary choice variables had been applied to the assessment of dietary intake in previous research. For example, similar to the methods applied in developing dietary choice categories in this study, in a study investigating folic acid supplementation among nonpregnant women (data from the Central Pennsylvania Women's Health 92 Study (CePAWHS)), authors created a combined category of fruit and vegetable intake from questionnaire responses regarding fruit and vegetable consumption (Evans & Weisman, 2010) . Furthermore, comparable to the current study, intake of fruit and vegetables was categorized as either once or more per day compared to less than once per day from response options of “never”, “once or twice a week”, “three or four times a week”, “five or six times a week”,” once a day”, or “more than once a day” (Evans & Weisman, 2010). Environmentally sustainable dietary choice items were coded as “Weekly” intake (≥ once per week) versus “Less than weekly”. Weekly intake was chosen as the outcome of interest, as it was considered to represent the frequency which may be realistic in terms of potential accessibility and efforts towards supporting environmental sustainability through dietary choices. From the response options provided in the two sets of questions from either a scale of “Never” to “2 or more times a week” (including the option “I don’t know”) or “Never” to “2 or more times a day” (including the option “I don’t know”), response options from “Never” to “2-3 times a month” were categorized as “Less than weekly” and remaining frequencies greater or equal to “1 time a week” were collapsed into the category of “Weekly” intake. The response option of “I don’t know” was combined with responses representing a frequency of “Less than weekly”. This decision was made based on the interpretation that a student who responded that they were not familiar with the item was most likely an indication that the student was not making the conscious decision to choose the item, and/or was therefore not likely to be consuming the item weekly. The environmentally sustainable dietary choice items “Food grown at a school” and “Food that you helped grow” were not expected to be highly reported among all students, due to the fact that specifically eating food grown by students themselves or eating food grown at a school would most likely require either the presence of a school garden, or the opportunity for students to 93 participate in gardening related activities. As a result, additional variables to be used in bivariate analyses with Gardening activities were created by dichotomizing reported frequencies from these dietary choice items into the two categories “Ever” versus “Never”, as these response categories were considered to be most important when evaluating associations between participation in an activity and dietary behavioural outcomes, due to the potential limited availability of these dietary choices among students. The response categories of “Ever” versus “Never” for these items were created by combining all frequency options greater than “Never” into the category “Ever”, and by combining the responses “Never” or “I don’t know” into the category of “Never”. The following items represented the final environmentally sustainable dietary choice items: Local food, Food that was purchased at a local farmers market, Food bought directly from a farm, Food grown at a school (weekly or ever), Food grown by someone you know, Food that you helped grow (weekly or ever), Food or beverages in recyclable packaging, Food or beverages in compostable packaging, Food from a Community Supported Agriculture (CSA) program. Similar to healthy dietary choice categories, environmentally sustainable dietary choice category variables were also created by combining several related individual FFQ items into one variable. For example Locally produced food was created by combining all individual FFQ items that represented locally produced dietary choices, such as “Food that was purchased at a local farmers market” and “Food bought directly from a farm”. The two categories of Locally produced food, and Food or beverages in recyclable or compostable packaging represented the final environmentally sustainable dietary choice categories. All environmentally sustainable dietary choice categories were dichotomized as “Weekly” intake versus “Less than weekly”, consistent with the dichotomization of individual environmentally sustainable dietary choices. However, in contrast to healthy dietary choice categories, where 94 measurement of intake was based on the sum of the reported frequencies of items within the category, environmentally sustainable dietary choice category variables were dichotomized as “Weekly” intake, based on reported intake of at least one item within the category at least once per week, versus “Less than weekly” intake, based on a reported intake of less than once per week for all items within the category. The frequency of “Weekly” intake of at least one item within a particular category was considered to represent the category of interest based on the same rationale described for the dichotomization of individual environmentally sustainable dietary choices, that a frequency of “Weekly” was considered to reflect regular intake of an environmentally sustainable dietary choice. The one less environmentally sustainable dietary choice item “Bottled Water” was dichotomized as “Daily” versus “Less than daily” using the same approach applied in generating healthy dietary choice item variables, by coding intake equal to or greater than once per day as “Daily” intake and coding remaining responses as “Less than daily”. “Daily” intake versus “Less than daily” was used to categorize intake of “Bottled Water”, due to the anticipation that student intake of water on school days would be frequent. Therefore, “Daily” intake of bottled water was perceived to most likely represent students who typically select bottled water when drinking water on school days, compared to other sources of water (such as tap water). 2.5.4.4 Food Practices The response category of importance for the healthy food practice variable related to breakfast consumption, Eat Breakfast, was considered to be daily intake, due to the benefits of consuming breakfast among children and adolescents (Shaw, 1998). Breakfast consumption was therefore dichotomized into “Daily” versus “Less than daily” by coding the response option of 95 “Once a day” from the 6 point scale of “Never” to “Once a day” as “Daily” consumption, and by coding remaining response options into the category of “Less than daily”. Due to the importance of not skipping meals, the less healthy food practice assessing whether students frequently “Eat nothing for lunch”, missing lunch at least once per week (Monday to Friday) in the past month was perceived to reflect a considerable number of missed school lunch meals. The food practice Eat nothing for lunch was therefore dichotomized into “Weekly” versus “Less than weekly” by combining response frequencies of “Once a week” or greater from the 6 point scale of “Never” to “Every school day” into the category of “Weekly”, and by categorizing the remaining responses as “Less than weekly”. The less healthy food practice variables pertaining to the purchase of items from fast food/ takeout establishments, convenience stores, and coffee shops, were created using a similar approach to the creation of the less healthy food practice Eat nothing for lunch. The frequency of intake of importance was established to be “Weekly” intake of food or beverages purchased at an establishment, for several reasons. In particular, it was not expected that all students would have equal availability of or accessibility to convenience food establishments on school days, including limited opportunities among many elementary school students to leave school during school hours, nor would all students necessarily have similar amounts of spending money for purchasing. Therefore, “Weekly” purchasing was considered to reflect a significant number of less healthy food or beverage purchases on school days. From the response options of “Never” to “2 or more times a day”, responses were dichotomized as “Weekly” versus “Less than weekly” using a similar approach as per the previous less healthy food practice of Eat nothing for lunch. The following variables represented the less healthy food practices reflecting purchasing at convenience food 96 establishments on school days: Fast food/takeout establishment purchasing, Convenience store purchasing, and Coffee shop purchasing, In contrast to healthy dietary choice category variables, the overall less health food practice category of Convenience food establishment purchasing was dichotomized into “Weekly” intake of at least one item within the category, compared to “Less than weekly” intake of all items. This approach was comparable to the approach used in creating the environmentally sustainable dietary choice category variables, based on the rationale that the most important factor with respect to purchasing food practices was whether students were regularly purchasing items from the same type of convenience food outlet. For the two environmentally sustainable food practices of Compost uneaten food at school, and Eat food grown in neighbourhood/community (including school), variables were dichotomized into “Weekly” versus “Less than weekly. The frequency of “Weekly” was considered to be the outcome of importance to represent regular composting or consumption of foods grown in the local neighbourhood/community (including school), as students were not anticipated to have either food on hand to compost on a daily basis or locally grown foods available daily for consumption. As the question evaluating environmentally sustainable food practices applied the same scale as the less healthy food practice “Eat nothing for lunch”, the same method was used to dichotomize this variable into “Weekly” versus “Less than weekly. However, using a similar approach to the environmentally sustainable dietary choices created specific to gardening, a second food practice variable reflecting Eat food grown in neighbourhood/community (including school) (ever), was created by dichotomizing item responses into “Ever” versus “Never”. As per the environmentally sustainable dietary choices specific to gardening dichotomized as “Ever”, this second version of the variable was used in bivariate analyses with Gardening activities, based on the rationale that 97 students were not expected to have the opportunity to eat food grown at school, at home, or in their community, on a regular basis. A list of food practice category variables (including dietary choice category variables) applied in bivariate analyses, and details of which questionnaire items were combined in generating each category, is provided in Appendix D. Please see the appendix table footnote a for the individual food practice items included in bivariate analyses. 2.5.5 Missing and Inconsistent Responses to Variables For all variables created from individual questionnaire items, when no response was selected for a questionnaire item, the variable was coded as missing. In addition, for all category variables created by a combination of individual questionnaire items, variables were coded as missing when no response was provided for all individual items included in the category. Due to the inability to establish whether a missing response to a particular question reflected an answer of “Yes” or “No”, overall missing responses for variables were not included in analyses. For example, a missing response may have been an indication of “No” to the question, however, a lack of response could have also resulted from a student who chose not to provide an answer, but represented a student who would have reported “Yes”. Furthermore, there appeared to be an inability to establish whether inconsistent responses to individual activities reflected a true participant or a true non-participant. For example, a true participant who selected “No” prior to recognizing they had participated in one or more of the locations provided in the response options, may have proceeded by selecting “Yes” to one or more of the additional options, to indicate they were a participant, without removing the selection of “No” to participation in the activity. However, there is an equal possibility that a student who was a true nonparticipant might have selected “Yes” to one or more options, if they had initially misinterpreted or misread the question, and then selected “No” to correct their response and indicate they had not 98 participated, without removing the “Yes” selection(s). Students who provided inconsistent responses were therefore not categorized as either “Yes” or “No” to participation and were removed from analyses. 2.6 Data Analysis 2.6.1 Statistical Tests Data were analyzed using Stata 12 software (StataCorp, 2011). Descriptive statistics were used to describe characteristics of the student participants, as well as to evaluate the prevalence of participation in different school food and nutrition programs overall and by school. Descriptive statistics were also used to assess dietary attitudes and expectations, and the reported frequency of dietary choices and food practices. Chi-square tests were applied to the measurement of differences in participation between genders and school types and to the evaluation of associations between SFNPs and outcomes. For this study, both the explanatory and outcome variables were categorical (nominal or ordinal), and as dietary intake data is known to be non-normally distributed, the chi-square test was chosen for bivariate analyses, as it is a non-parametric test that can be applied to categorical data (McHugh, 2013). The chi-square test has also been applied in previous studies evaluating associations between variables and dietary outcomes. For example, in the study by Gosliner et al. (2011), authors used a chi-square analysis to measure whether an association existed between dietary intake of items at school and student reported attitudes regarding the importance of the availability of items at school. Furthermore, in the present study, observations among students attending the same school may not have been entirely independent; therefore, the Rao-Scott correction (Rao & Scott, 1981) was applied to chi-square tests, as it takes into account the potential for clustering and non-independence of observations in the study design (personal communications 99 with research team members, 2013). A Rao-Scott second-order correction was used for all bivariate analyses. Statistical significance for an association between variables was set at p < 0.05. 2.6.1.1 Variables Included in Bivariate Analyses between SFNPs and Outcomes All five activity categories, in addition to the food or nutrition related learning activities Learning about Canada’s Food Guide and Learning about foods grown in British Columbia, represented the key food and nutrition program activity exposures of interest, and were the SFNP variables used in the descriptives of school-level participation and in the bivariate analyses with student characteristics and dietary psychosocial and behavioural outcome variables. A list of all variables included in bivariate analyses is presented in Table 2-3 (with the exception of variables indicated by a). Unless otherwise specified by the term “individual activities” or the name of a specific individual activity, the terms “activity categories”, “categories” or “activities” used throughout the results, discussion, and conclusions, will be used to refer to the five activity categories in addition to the two food-specific learning activities, Learning about Canada’s Food Guide and Learning about foods grown in British Columbia, as results of school-level participation and all bivariate analyses pertain only to these seven activities. Due to the low response rate for participation in SFNP clubs, and the low participation rate reported in teaching cafeterias, these variables were not used in further analyses. Only 11% (n=102) of the total sample of students reported being a member of any of the clubs listed over the past school year, and approximately 74% (n=696) of students in the sample did not respond to whether they had participated. Furthermore, only 14% (n=129) of students reported that their school had a teaching cafeteria, and 36% (n=326) reported “I don’t know”. Of the students who were provided with a follow-up question as to whether they had worked in the teaching cafeteria this school year, overall only 4% (n=34) out of the total sample (n=937) reported participation. A total of 806 100 students (86%) were categorized as missing for this item, either as a result of not receiving the follow-up question or not responding. The final dietary outcome variables used in bivariate analyses with SFNPs included all attitudes and expectations described, and all healthy and less healthy dietary choice variables. However, in terms of environmentally sustainable dietary choice variables, only the two overall environmentally sustainable choice categories were selected. All healthy and environmentally sustainable food practices were applied with the exception of the individual convenience food purchasing items, which included: Fast food/takeout establishment purchasing, Convenience store purchasing, and Coffee shop purchasing. The environmentally sustainable dietary choice categories and the less healthy dietary food practice category were chosen for bivariate analyses as opposed to the individual items within the categories, as there did not appear to be a strong rationale to evaluate individual items in most cases. However, as introduced in the description of dichotomization of variables, the individual environmentally sustainable dietary choice variables, Food grown at a school (ever) and Food that you helped grow (ever), were chosen to be specifically included in the bivariate analyses with school gardening activities, in addition to the other environmentally sustainable dietary choice categories, based on the expectation that students who reported participating in school gardening activities may have had a greater opportunity to eat food grown at a school or food that they helped grow, compared to students who did not have access to a garden at a school. In addition, as discussed in the description of food practice variables, the food practice of “Ever” eating food grown in their neighbourhood/community (including school) was also tested uniquely with school gardening activities, due to its believed distinctive relevance to this activity. Lastly, as composting would not necessarily be available at all schools, the food practice of 101 composting uneaten food at school was included only in bivariate analyses with Composting activities, due to its anticipated association with this activity. 2.6.1.2 Categorization of SFNPs and Expected Associations with Dietary Psychosocial and Behavioural Outcomes Based on the potential learning and/or hands-on experiences included in the described activities, the SFNP activity categories included in this study were further categorized into either activities that specifically involve learning about food or nutrition or activities focussing on food-related hands-on experiences. Learning activities included the SFNP activity categories Learning about Canada’s Food Guide and Learning about foods grown in British Columbia. The hands-on food-related activities included the remaining categories of Food Preparation activities, Choosing or Tasting Healthy Foods activities, Gardening activities, Composting activities, and Recycling activities. Furthermore, in comparison to Gardening activities, Composting activities, and Recycling activities, where students may not always be specifically learning about food or nutrition or working with food as part of the activity, the four activities, Food Preparation activities, Choosing or Tasting Healthy Foods activities, Learning about Canada’s Food Guide, and Learning about foods grown in British Columbia, were considered to be food-specific activities, due to their focus on food. Each SFNP activity category was further categorized as being associated with specific healthy and/or environmentally sustainable outcomes based on the activities included in each category. As all activities related to either health, environmental sustainability, or both, all activities were therefore tested with the both healthy and environmental sustainability outcomes (outcomes considered to relate to health as well as environmental sustainability). With regard to the categorization of activities by their expected associations with healthy and/or environmentally sustainable outcomes, Food preparation activities, Choosing or tasting 102 healthy foods activities, and Learning about Canada’s Food Guide, were categorized as relating to healthy outcomes. Table 2-4 provides a summary of the dietary psychosocial and behavioural outcome categories tested in bivariate analyses with SFNP activity categories based on their expected associations with each activity. Firstly, food preparation activities were believed to reflect healthy dietary psychosocial and behavioural outcomes, as these school activities would most likely involve the preparation of healthy foods. Secondly, activities where students are choosing or tasting healthy foods were also considered to relate to healthy dietary outcomes, as they were anticipated to directly involve the promotion of healthy dietary choices and food practices among students. Thirdly, activities involving learning about Canada’s Food Guide were also expected to relate specifically to healthy outcomes in accordance with Canada’s Food Guide recommendations. Activities where students are learning about foods grown in British Columbia may provide lessons on locally grown fresh foods, such as fruits and vegetables, and the potential benefits of local food production towards environmental sustainability. Therefore, the activity was expected to relate to specific healthy and/or environmentally sustainable dietary psychosocial and behavioural outcomes that were considered to directly pertain to this activity. Learning about foods grown in British Columbia was therefore not tested with the healthy dietary attitude towards the importance of healthy when making food purchases on school days, with the one healthy dietary expectation, or with food practices, and was only tested with the following dietary choices: daily intake of Vegetables, Fruit, Vegetables or fruit, and Snack foods, and weekly intake of Locally produced food. Gardening activities, where students are growing food in a garden, was expected to often involve planting fruits and/or vegetables, and to potentially include lessons promoting overall 103 healthy dietary choices, including fresh vegetables or fruits. Furthermore, growing local food as part of this activity may also incorporate lessons on the implications of locally produced food on environmental sustainability, and encourage further environmentally sustainable dietary choices among students. As a result, Gardening activities was expected to relate to both healthy and environmentally sustainable outcomes. In addition, as described in the section regarding final outcome variables included in the bivariate analyses with SFNP activities, the environmentally sustainable dietary choices of Food grown at a school (ever) and Food that you helped grow (ever), and the environmentally sustainable food practice Eat food grown in neighbourhood/community (including school) (ever), were also expected to specifically relate to Gardening activities. Both composting and recycling were considered to reflect environmentally sustainable activities. Composting activities was anticipated to relate to environmental sustainability, as compost assists in minimizing the disposal of organic waste and contributes to soil health for use in agriculture (Stan et al., 2009). However, as activities involving composting may not directly involve working with food or learning about healthy dietary choices, composting activities were anticipated to only be associated with environmentally sustainable outcomes. The environmentally sustainable food practice Compost uneaten food at school (weekly) was also tested with this activity, due to the expected association between this food practice and Composting activities, as described in the section regarding final outcome variables included in bivariate analyses with SFNP activities. Similar to composting, recycling activities may focus on the benefits of recycling to environmental sustainability, such as reducing the amount of waste generated (Harmon & Gerald, 2007). Therefore, as recycling may not specifically address healthy eating, recycling was anticipated to relate only to environmentally sustainable outcomes. 104 Table 2-4 – Dietary psychosocial and behavioural outcomes included in bivariate analyses with SFNP activity categories and expected associations with dietary psychosocial and behavioural outcomes SFNP Activity Category Healthy and Less Healthy Outcomes d Environmentally Sustainable and Less Environmentally Sustainable Outcomes e Both Healthy and Environmentally Sustainable or Both Less Healthy and Less Environmentally Sustainable Outcomes f Food preparation activities √ / √ Choosing or tasting healthy foods activities √ / √ Learning about Canada’s Food Guide √ / √ Learning about foods grown in British Columbia a √ √ √ Gardening activities b √ √ √ Composting activities c / √ √ Recycling activities / √ √ a Learning about foods grown in British Columbia not tested with the following variables: Healthy Dietary Attitude: Food Purchasing - Importance of Food Type (Importance healthy), Healthy Dietary Expectation (Food choices - agree affect health), or food practices. Activity only tested with the following dietary choices: (daily) Vegetables, Fruit, Vegetables or fruit, and Snack foods, and Locally produced food (weekly) b Gardening activities was tested with all dietary outcome variables in addition to the dietary choice variables Food grown at a school (ever), Food that you helped grow (ever), and the food practice Eat food grown in neighbourhood/community (including school) (ever) c Composting activities was also tested with the variable Compost uneaten food at school (weekly) d Activity category expected to show positive associations with Healthy outcomes and negative associations with Less Healthy Outcomes e Activity category expected to show positive associations with Environmentally Sustainable Outcomes and negative associations with Less Environmentally Sustainable Outcomes f Activity category expected to show positive associations with Both Healthy and Environmentally Sustainable Outcomes and negative associations with Both Less Healthy and Less Environmentally Sustainable Outcomes √ Activity category was tested with dietary psychosocial and/or behavioural outcomes represented by this category. See exceptions a, b, c. Additional variables tested with Gardening activities and Composting activities were not tested with other activity categories. / Activity categories not tested with outcome variables 105 Chapter 3: Results 3.1 Student Characteristics The final sample included 937 students from 20 elementary schools and 6 secondary schools in the Vancouver School District. Student characteristics are reported in Table 3-1. The final sample had a similar proportion of males (51%, n=480) and females (49%, n=455). However, the sample consisted of a much larger percentage of elementary school students (74%, n=697)) compared to secondary school students. The majority of participants were in grade 7 (59%, n=546). Approximately 80% of participants were between the ages of 12-13 (n=745), and the mean age was 12.5 years (SD=0.81). Over three-quarters of students (n=673) reported being born in Canada. Yet, a similar percentage of students (78%, n=680) reported that one or more parent(s) or primary caregiver(s) were born outside of Canada.106 Table 3-1 – Student characteristics n % Total Participants 937 100 Gender Male 455 51 Female 480 49 School type Elementary 697 74 Secondary 240 26 Grade 6 139 15 7 546 59 8 238 26 Age 11 84 9 12 405 43 13 340 36 14 105 11 15 1 <1 Country of birth Born in Canada 673 75 Born outside Canada 220 25 Parent(s) or primary caregiver(s) country of birth Born in Canada 196 22 ≥ 1 Born outside Canada 680 78 107 3.2 Participation in School Food and Nutrition Programs 3.2.1 Student-Level Participation in Individual SFNP Activities Participation in individual school activities is presented in Table 3-2. Participation in all individual activities was below 50%. The percentage of students stating that they had participated in individual activities where they were engaged in learning about the activity, such as Learning how to recycle, was always higher compared to the percentage of students stating they had participated in the activity independently (“on my own”), such as Recycling on my own. The activity reported least frequently was “Grocery shopping on my own” (3%, n= 24), and the activity most commonly reported was “Learning how to recycle” (48%, n=406). In terms of participation in healthy related activities, Learning about Canada’s Food Guide was the activity most frequently reported (45%, n=380). Very few students reported participation in grocery shopping activities, including Learning how to grocery shop (4%, n=37) or Grocery shopping on my own (3%, n=24). Though approximately 30% of students reported participating in Learning how to cook (n=266), a lower percentage stated they had participated in activities Preparing healthy foods (15%, n=128) or Tasting healthy foods (17%, n=148). With respect to participation in environmentally sustainable related activities, slightly less than 30% of students (n=241) stated they had participated in Learning how to make compost. However, overall, the activity most highly reported among environmentally sustainable activities, as well as among all individual activities, was Learning how to recycle (48%, n=406). 108 Table 3-2 – Student-level participation in individual school food and nutrition program (SFNP) activities (n=937) Individual Activity a Yes b n % Healthy Activities Learning how to cook 266 31 Cooking on my own 72 8 Learning how to grocery shop 37 4 Grocery shopping on my own 24 3 Choosing healthy foods 183 22 Preparing healthy foods 128 15 Tasting healthy foods 148 17 Learning about Canada’s Food Guide 380 45 Both Healthy and Environmentally Sustainable Activities Learning about foods grown in British Columbia 297 35 Learning how to grow food in a garden 174 20 Growing food in a garden on my own 59 7 Environmentally Sustainable Activities Learning how to make compost 241 29 Composting on my own 145 17 Learning how to recycle 406 48 Recycling on my own 325 38 a Individual activity refers to the individual activity listed in the following survey questions: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in the individual activity listed. Results of participation in both healthy and environmentally sustainable related activities, revealed that Learning about foods grown in British Columbia was the fourth most frequently reported individual activity (35%, n=297), following recycling activities and Learning about Canada’s Food Guide. In contrast, the percentage of students stating they had participated in Learning how to grow food in a garden was only 20% (n=174), and very few students reported Growing food in a garden on my own (7%, n=59). 109 3.2.2 Student-Level Participation in SFNP Activity Categories Participation rates in overall activity categories at school are presented in Table 3-3. With the exception of recycling, well below 50% of students reported participating in the remaining school activity categories, which included food-specific activities, gardening, and composting. In addition, it was found that overall only 2% of students (n=20) reported participating in all activity categories at school this year. However, in comparison, 20% of students (n=179) reported that they have not participated in any activity category this school year. (Results of overall participation in all or no activity categories are not presented in table format). As was seen for results of participation in the two individual recycling activities, the most highly reported activity category was recycling (51%, n=445). The activity category for which students reported the lowest participation was gardening (21%, n=184). 110 Table 3-3 – Student-level participation in school food and nutrition program (SFNP) activity categories (n=937) Activity Category a Yes g n % Food preparation activities b 326 36 Choosing or tasting healthy foods activities c 238 27 Gardening activities d 184 21 Composting activities e 273 32 Recycling activities f 445 51 a Activity categories include a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply.". b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own e The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own f The Recycling activities category includes the following individual activities: Learning how to recycle, Recycling on my own g "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in one or more individual activities combined in a category. 3.2.3 School-Level Participation in SFNP Activity Categories Descriptive results of overall participation among schools in each activity category, as well as in the individual activities Learning about Canada’s Food Guide and Learning about foods grown in British Columbia, showed that the median participation reported at each school in learning activities and activity categories was below 50%, with the exception of Recycling activities (52%) (Table 3-4). The upper quartile (75th) for participation in all activity categories was ≤ 60%. Furthermore, the study found that the maximum percentage participation reported by students for each activity category by school was above 2/3, with the exception of Choosing or tasting healthy foods activities (48%). 111 Table 3-4 – School-level participation in school food and nutrition program (SFNP) activity categories (n=26) (five-number summary) Activity Category a Minimum Q1 (1st Quartile) Median Q3 (3rd Quartile) Maximum % i % % % % Food preparation activities b 4 16 21 50 88 Choosing or tasting healthy foods activities c 4 19 26 29 48 Learning about Canada’s Food Guide d 0 24 35 59 91 Learning about foods grown in British Columbia e 10 26 33 43 67 Gardening activities f 0 10 18 34 73 Composting activities g 0 21 29 44 73 Recycling activities h 21 44 52 60 87 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" e The Learning about foods grown in British Columbia category refers to participation in the individual activity "Learning about foods grown in British Columbia" f The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own g The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own h The Recycling activities category includes the following individual activities: Learning how to recycle, Recycling on my own i Percentage (%) reflects the proportion of students at each school who reported "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. Descriptive results of participation in activity categories among schools also revealed that a wide range of variability existed in participation in each activity category between schools, as well as between activity categories within schools. For example, the lowest percentage of participation 112 reported at a school for the activity Learning about Canada’s Food Guide was 0%, whereas the highest percentage reported was 91%. Graphs showing the overall percentage of students reporting participation in each activity category at each school from lowest to highest are presented in Appendix E. The graphs revealed large variability in participation in each activity among schools. Variation can also be seen in participation rates between activities at each particular school, as some schools had high reported participation rates in most activities whereas other schools had low participation rates in most activities. 3.2.4 Participation in SFNP Activity Categories by Gender and School Type Differences in participation in SFNPs between genders, including their significance, are presented in Table 3-5. A significant difference in participation between genders was only found for the activities Learning about Canada’s Food Guide (p= 0.007) and Learning about foods grown in British Columbia (p=0.000). For example, for the activity Learning about Canada’s Food Guide, 49% of female respondents reported participation, compared to 41% of males. 113 Table 3-5 – Student-level participation in school food and nutrition program (SFNP) activity categories by gender and by school type (n=937) Activity Category a Male Female Elementary Secondary % % p j % % p Food preparation activities b Yes i 35 38 0.326 22 77 0.000 n 453 440 657 237 Choosing or tasting healthy foods activities c Yes 27 27 0.889 23 37 0.002 n 448 437 651 235 Learning about Canada’s Food Guide d Yes 41 49 0.007 36 68 0.001 n 427 421 620 229 Learning about foods grown in British Columbia e Yes 30 41 0.000 32 45 0.047 n 426 416 615 228 Gardening activities f Yes 20 22 0.635 23 17 0.368 n 437 431 639 230 Composting activities g Yes 29 34 0.169 32 29 0.656 n 437 428 635 231 Recycling activities h Yes 48 55 0.134 51 51 0.944 n 438 431 640 230 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" 114 e The Learning about foods grown in British Columbia category refers to participation in the individual activity "Learning about foods grown in British Columbia" f The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own g The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own h The Recycling activities category includes the following individual activities: Learning how to recycle, Recycling on my own i "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. j P-value of Rao-Scott corrected chi-square test. Result significant for p < 0.05. Evaluation of the differences in participation in activity categories between elementary school students and secondary school students showed that participation was significantly higher among secondary schools students for the activity Learning about foods grown in British Columbia (p=0.047), as well as for all activities related specifically to healthy dietary psychosocial and behavioural outcomes, including Food preparation activities (p=0.000), Choosing or tasting healthy foods activities (p=0.002), and Learning about Canada’s Food Guide (p=0.001). Results are presented in Table 3-5. There were no significant differences in participation in gardening and composting activities by school type (elementary versus secondary). The rate of participation in recycling activities between school types was similar. 3.3 Healthy and Environmentally Sustainable Dietary Attitudes Descriptive findings of dietary attitudes revealed that the majority of students reported healthy, environmentally sustainable, and both healthy and environmentally sustainable dietary attitudes towards food or beverage purchases on school days, with the exception of local items (42%, n=371). Results can be found in Table 3-6. The highest reported attitude towards the importance of a specific food type when making school day purchases of food or beverages was for 115 the item being healthy (83%, n=736). However, the percentage of students who responded that it was important that the item includes vegetable was much lower (69%, n=617). Though 62% stated that it was important that the items are environmentally friendly (n=543), less than half this percentage of students said they cared about “How food choices impact the environment” (26%, n=214). Lastly, a similar percentage of students reported that fresh rather than packaged (72%, n=644) and minimally processed (71%, n=614) items were important when making purchases. 116 Table 3-6 – Healthy and environmentally sustainable dietary attitudes among students (n=937) Dietary Attitudes n % e Somewhat important/ Very important c Healthy Dietary Attitudes Food Purchasing - Importance of Food Type a Importance fresh vegetables 617 69 Importance healthy 736 83 Environmentally Sustainable Dietary Attitudes Importance local 371 42 Importance environmentally friendly 543 62 Very much d Food Choices - Caring about impact b Food choices - care very much impact on environment 214 26 Somewhat important/ Very important Both Healthy and Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vs. packaged 644 72 Importance minimally processed 614 71 a Attitudes related to food purchasing refer to the following survey question: "If you were to buy food or beverages on school days (either during school hours or on your way to or from school), how important would it be to you that…". Items begin with either "The food includes..." or "The food is..." b Attitude related to the impact of food choices on the environment refers to the following survey question and item: "How much do you care about…." "How food choices impact the environment" c Response options for purchasing attitudes dichotomized as "Not at all important" / "Not very important" versus "Somewhat important"/ "Very important" d Response options for caring attitude dichotomized as "Not at all " / "A little bit" / "Somewhat" versus "Very much" e Percentage (%) refers to the proportion of students who reported the response option(s) from the survey listed in the results table. 117 3.4 Healthy and Environmentally Sustainable Dietary Expectations Results of dietary expectations towards the impact of food choices (Table 3-7) revealed that the majority of students reported healthy and environmentally sustainable expectations. However, compared to the percentage of students reporting the dietary attitude of the importance of “healthy” when making food or beverage purchases on school days, fewer students stated they agreed with the expectation that food choices affect health (69%, n=552). Furthermore, though only approximately one quarter of students stated they cared about “How food choices impact the environment”, almost twice as many students (52%, n=420) reported that they agreed that food choices affect the environment. Table 3-7 – Healthy and environmentally sustainable dietary expectations among students (n=937) Dietary Expectations a n % c Agree/ Strongly agree b Healthy Dietary Expectation Food choices - agree affect health 552 69 Environmentally Sustainable Dietary Expectation Food choices - agree affect environment 420 52 a Expectations related to food choices affecting health or the environment refer to the following survey question and items: "How strongly do you agree with the following statements? The types of food I eat affects:" "My health" and "The environment". b Response options for expectations dichotomized as "Strongly disagree" / "Disagree" / "Neither agree nor disagree” versus "Agree"/ "Strongly agree" c Percentage (%) refers to the proportion of students who reported the response options from the survey listed in the results table. 118 3.5 Healthy and Environmentally Sustainable Dietary Choices on School Days With regard to results of healthy dietary choice items and categories, fifty percent or less of students reported daily school day intake of Vegetables (42%, n=385), fruit (50%, n=461), Whole grains (35%, n=321), and Low-fat milk or soy beverages (47%, n=423). However, overall 63% of students (n=588) stated that they consumed Vegetables or fruit on a daily basis. In addition, the majority of students reported daily intake of Water on school days (79%, n=728). Descriptive results of dietary choices are presented in Table 3-8. Table 3-8 – Healthy and environmentally sustainable dietary choices among students on school days (n=937) Dietary Choices n % Daily d Healthy Dietary Choice Item and Categories a Vegetables c 385 42 Fruit c 461 50 Vegetables or fruit c 588 63 Whole grains 321 35 Low-fat milk or soy beverages c 423 47 Water c 728 79 Less Healthy Dietary Choice Categories a Sugar-sweetened beverages c 289 31 Energy dense entrees or side dishes c 161 17 Weekly e Environmentally Sustainable Dietary Choice Items and Categories b Local food 350 38 Food that was purchased at a local farmers market 289 32 Food bought directly from a farm 64 7 Food grown at a school 53 6 Food grown by someone you know 143 16 119 Dietary Choices n % Weekly e Environmentally Sustainable Dietary Choice Items and Categories Food that you helped grow 241 26 Food or beverages in recyclable packaging 369 41 Food or beverages in compostable packaging 208 23 Food from a Community Supported Agriculture (CSA) program 57 6 Locally produced food c 542 58 Food or beverages in recyclable or compostable packaging c 401 44 Ever f Food grown at a school 197 22 Food that you helped grow 463 51 Daily d Less Environmentally Sustainable Dietary Choice Item a Bottled water 250 28 Both Less Healthy and Less Environmentally Sustainable Dietary Choice Category a Snack foods c 191 20 a Dietary choice items refer to individual items and categories refer to a combination of items listed in the following survey questions: "Looking back on the past 30 days, on average, how often did you [drink / eat] the following on school days (either during school hours or on your way to or from school)?". Responses were provided on a 7-point likert scale from "Never" to "2 or more times a day". b Dietary choice items refer to individual items and categories refer to a combination of items listed in the following survey questions: "Looking back on the past YEAR, on average, how often did you eat the following on school days (either during school hours or on your way to or from school)?". Responses options for the first five individual items listed in the results table were provided on a 5-point likert scale from "Never" to "2 or more times a week". Response options for the sixth to ninth individual items were provided on a 7-point likert scale from "Never" to "2 or more times a day". Both likert scales included a sixth or eighth option of "I don't know". c Variable represents a category variable. Remaining variables represent individual item variables. d "Daily" refers to students who reported intake of ≥ once per day of an item for individual variables or a total intake of ≥ once per day of any combination of items within a category for category variables. e "Weekly" refers to students who reported intake of ≥ once per week of an item for individual variables or intake of ≥ 1 item within a category ≥ once per week for category variables. f "Ever" refers to students who reported any intake > never of an item for individual variables. 120 Descriptive results of less healthy dietary choices revealed that all choices were consumed less frequently on a daily basis compared to healthy choices. The most commonly reported less healthy option consumed daily was Sugar-sweetened beverages (31%, n=289). Results of dietary intake of environmentally sustainable dietary choice items and categories showed that less than 50% of students reported weekly intake of any individual item. The item most frequently reported on a weekly basis was intake of Local food (38%, n=350), whereas the item least frequently reported was Food grown at a school (6%, n=53). However, approximately half of students reported they have ever consumed Food that you helped grow (51%, n=463), though less than a quarter of students recalled consuming Food grown at a school (ever) (22%, n=197). Overall, the combined variable of Locally produced food, showed that over half of students reported weekly intake of at least one environmentally sustainable dietary choice item (58%, n=542). Nonetheless, still less than half of students recalled overall weekly intake of Food or beverages in recyclable or compostable packaging (44%, n=401). The majority of students did not report daily dietary intake of either less environmentally sustainable or both less healthy and less environmentally sustainable dietary choices. Slightly less than 30% of students (n=250) reported daily consumption of Bottled water. Consumption of Snack foods on a daily basis was recalled by 20% of students (n=191). 3.6 Healthy and Environmentally Sustainable Food Practices on School Days Results related to the food practices of breakfast and lunch intake revealed that the majority of students reported consumption of breakfast and lunch on school days. Findings for food practices can be found in Table 3-9. However, despite almost 40% (n=357) of students reporting not eating breakfast daily in a typical month (miss breakfast at least once per week), a lower proportion of 121 students (14%, n=130) stated that they Eat nothing for lunch once per week or more in a typical month. The percentage of students who reported “Never” Eat nothing for lunch in a typical month was 58% (n=528). Table 3-9 – Healthy and environmentally sustainable food practices on school days (n=937) Food Practices n % Daily d Healthy Food Practice Item Eat breakfast a 563 61 Weekly e Less Healthy Food Practice Items and Category b Eat nothing for lunch 130 14 Fast food/takeout establishment purchasing 152 17 Convenience store purchasing 161 18 Coffee shop purchasing 72 8 Convenience food establishment purchasing 262 29 Environmentally Sustainable Food Practice Items c Eat food grown in neighbourhood/community (including school) 77 9 Compost uneaten food at school 113 13 Ever f Eat food grown in neighbourhood/community (including school) 240 27 a The food practice Eat breakfast refers to the following survey question and item: "In a typical month, on Monday through Friday (anytime of the day), how often do you…" "Eat breakfast". Response options were provided on a 6-point likert scale from "Never" to "Once a day". b The food practice Eat nothing for lunch refers to the following survey question and item: "In a typical month, how often do you do each of the following on school days (either during school hours or on your way to or from school)?" "Eat nothing for lunch". Response options were provided on a 6-point likert scale from "Never" to "Every school day". The food practices related to convenience food establishment purchasing refers to the following survey question and items: "In a typical month, how often do you drink or eat food that you purchased at the following places on school days (either during school hours or on your way to or from school)?" "Fast food or take out restaurant or food court", "Convenience store (such as 7-Eleven)", and "Coffee shop". Response options were provided on a 7-point likert scale from "Never" to "2 or more times a day". The Convenience food establishment purchasing category included all three individual purchasing items. 122 c The environmentally sustainable food practices reflect the following survey question and items: "In a typical month, how often do you do each of the following on school days (either during school hours or on your way to or from school)?" "Eat food grown at school, at home or in your community (for example in a garden, in balcony planters, or in an orchard or greenhouse)?", and "Put leftover food that you didn’t finish eating into a compost bin at school". Response options were provided on a 6-point likert scale from "Never" to "Every school day". d "Daily" refers to students who reported a frequency of ≥ once per day of an item for individual variables or a total frequency of ≥ once per day of any combination of items within a category for category variables. e "Weekly" refers to students who reported a frequency of ≥ once per week of an item for individual variables or a frequency of ≥ once per week of ≥ 1 item within a category for category variables. f "Ever" refers to students who reported any frequency > never of an item for individual variables. The less healthy food practices related to purchasing at convenience food establishments revealed that less than 20% of students reported Fast food/takeout establishment purchasing (17%, n=152) or Convenience store purchasing (18%, n=161) on a weekly basis. Purchasing items from a coffee shop was reported the least frequently out of the three convenience food establishments listed (8%, n=72). The percentage of students who reported overall Convenience food establishment purchasing on a weekly basis was 29% (n=262). Of the two environmentally sustainable food practice items related specifically to gardening or composting, very few students reported that they Compost uneaten food at school at least once per week (13%, n=113), whereas fewer students stated that they Eat food grown in neighbourhood/community (including school) at least once per week (9%, n=77). In addition, slightly less than 30% of students recalled that they had “Ever” eaten food grown in their neighbourhood/community (including school) (27%, n=240). 123 3.7 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations Overall, very few associations were found between participation in SFNP activities and dietary attitudes and expectations. In addition, significant associations were not always in the expected direction. Table 3-10 presents the results of bivariate analyses between each activity and dietary attitudes. Results of associations between each activity and dietary expectations are presented in Table 3-11. 124 Table 3-10 – Associations between participation in activity categories and healthy and environmentally sustainable dietary attitudes (n=937) Dietary Attitudes Activity Category a No Yes i No Yes % % p l % % p Food preparation activities b Choosing or tasting healthy foods activities c Healthy Dietary Attitudes Food Purchasing - Importance of Food Type j Importance fresh vegetables Yes 71 67 0.253 69 71 0.548 n 548 317 629 230 Importance healthy Yes 83 83 0.958 83 85 0.489 n 543 316 625 229 125 Dietary Attitudes Activity Category a No Yes i No Yes % % p l % % p Food preparation activities Choosing or tasting healthy foods activities Both Healthy and Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vs. packaged Yes 73 70 0.326 73 70 0.355 n 548 319 632 230 Importance minimally processed Yes 72 70 0.651 70 72 0.608 n 535 313 621 225 126 Dietary Attitudes Activity Category a No Yes i No Yes % % p l % % p Learning about Canada’s Food Guide d Learning about foods grown in British Columbia e Healthy Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vegetables Yes 67 73 0.046 66 75 0.006 n 456 369 533 285 Importance healthy Yes 83 84 0.560 / n 452 368 Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance local Yes / 41 44 0.351 n 531 287 127 Dietary Attitudes Activity Category a No Yes i No Yes % % p l % % p Learning about Canada’s Food Guide Learning about foods grown in British Columbia Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance environmentally friendly Yes / 61 64 0.244 n 532 286 Food Choices - Caring about impact k Food choices - care very much impact on environment Yes / 26 23 0.481 n 484 273 128 Dietary Attitudes Activity Category a No Yes i No Yes % % p l % % p Learning about Canada’s Food Guide Learning about foods grown in British Columbia Both Healthy and Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vs. packaged Yes 73 72 0.724 72 74 0.608 n 457 371 535 287 Importance minimally processed Yes 69 74 0.095 69 74 0.237 n 452 365 531 280 129 Dietary Attitudes Activity Category a No Yes i No Yes No Yes % % p l % % p % % p Gardening activities f Composting activities g Recycling activities h Healthy Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vegetables Yes 70 65 0.339 / / n 672 175 Importance healthy Yes 83 81 0.562 / / n 671 172 Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance local Yes 40 48 0.064 42 43 0.654 45 39 0.024 n 665 174 575 262 409 429 Importance environmentally friendly Yes 61 62 0.866 61 65 0.236 64 60 0.341 n 664 173 574 262 408 430 130 Dietary Attitudes Activity Category a No Yes i No Yes No Yes % % p l % % p % % p Gardening activities Composting activities Recycling activities Environmentally Sustainable Dietary Attitudes Food Choices - Caring about impact Food choices - care very much impact on environment Yes 28 20 0.085 28 22 0.083 30 23 0.052 n 619 164 524 258 374 412 Both Healthy and Environmentally Sustainable Dietary Attitudes Food Purchasing - Importance of Food Type Importance fresh vs. packaged Yes 74 65 0.018 73 72 0.696 75 70 0.048 n 675 173 582 264 418 432 Importance minimally processed Yes 72 67 0.369 71 70 0.680 72 69 0.418 n 661 169 571 258 406 425 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." 131 b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" e The Learning about foods grown in British Columbia category refers to participation in the individual activity "Learning about foods grown in British Columbia" f The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own g The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own h The Recycling activities category includes the following individual activities: Learning how to recycle, Recycling on my own i "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. j Attitudes related to food purchasing refer to the following survey question: "If you were to buy food or beverages on school days (either during school hours or on your way to or from school), how important would it be to you that…". Items begin with either "The food includes..." or "The food is..." "Yes" to each item refers to the percentage of students who reported either "Somewhat important"/ "Very important" versus those who reported "Not at all important" or "Not very important". k Attitude related to the impact of food choices on the environment refers to the following survey question and item: "How much do you care about…." "How food choices impact the environment". "Yes" to the item refers to the percentage of students who reported "Very much" compared to students who reported "Not at all " / "A little bit" / "Somewhat". l P-value of Rao-Scott corrected chi-square test. Result significant for p < 0.05. / Activity categories not tested with outcome variables Note: Food preparation activities and Choosing or tasting healthy foods activities were not tested with Environmentally Sustainable Dietary Attitudes. Therefore, results of bivariate analyses between these activities and these outcomes are not listed in table. 132 Table 3-11 – Associations between participation in activity categories and healthy and environmentally sustainable dietary expectations (n=937) Dietary Expectations Activity Category a No Yes i No Yes % % p k % % p Food preparation activities b Choosing or tasting healthy foods activities c Healthy Dietary Expectation j Food choices - agree affect health Yes 67 71 0.191 68 70 0.579 n 493 294 574 208 Learning about Canada’s Food Guide d Learning about foods grown in British Columbia e Healthy Dietary Expectation Food choices - agree affect health Yes 65 74 0.011 / n 405 348 133 Dietary Expectations Activity Category a No Yes i No Yes % % p k % % p Learning about Canada’s Food Guide Learning about foods grown in British Columbia Environmentally Sustainable Dietary Expectation j Food choices - agree affect environment Yes / 49 58 0.009 n 483 265 134 Dietary Expectations Activity Category a No Yes i No Yes No Yes % % p k % % p % % p Gardening activities f Composting activities g Recycling activities h Healthy Dietary Expectation Food choices - agree affect health Yes 69 67 0.681 / / n 616 158 Environmentally Sustainable Dietary Expectation Food choices - agree affect environment Yes 52 50 0.678 52 51 0.802 55 49 0.131 n 614 159 517 253 375 400 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" e The Learning about foods grown in British Columbia category refers to participation in the individual activity "Learning about foods grown in British Columbia" f The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own 135 g The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own h The Recycling activities category includes the following individual activities: Learning how to recycle, Recycling on my own i "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. j Expectations related to food choices affecting health or the environment refer to the following survey question and items: "How strongly do you agree with the following statements? The types of food I eat affects:" "My health" and "The environment". "Yes" to each item refers to the percentage of students who reported either "Agree"/ "Strongly agree" versus those who responded "Strongly disagree"/ "Disagree" / "Neither agree nor disagree”. k P-value of Rao-Scott corrected chi-square test. Result significant for p < 0.05. / Activity categories not tested with outcome variables Note: Food preparation activities and Choosing or tasting healthy foods activities not tested with Environmentally Sustainable Dietary Expectation. Therefore, results of bivariate analyses between these activities and this outcome are not listed in table.136 Results of associations between participation in food-specific activities and dietary psychosocial outcomes revealed expected associations between participation in activities and dietary attitudes and expectations. Learning about Canada’s Food Guide was positively associated with the attitude of vegetables being important when purchasing food (p=0.046). Though a positive association was also found between the activity and the expectation that food choices affect health (p=0.011), no associations were found with remaining healthy dietary attitudes towards food purchasing, including the importance of the item being healthy. Learning about foods grown in British Columbia was also significantly and positively associated with vegetables being important when making food and beverage purchases (p=0.006), and agreement with the environmentally sustainable expectation that food choices affect the environment (p=0.009). However, no statistically significant association was found with the attitude of caring about the impact of food choices on the environment. No significant associations were found between the hands-on activities, Food preparation activities and Choosing or tasting healthy foods activities, and healthy dietary attitudes and expectations. Results of associations between participation in hands-on activities related to environmental sustainability or both health and environmental sustainability and dietary attitudes and expectations revealed only associations in the unexpected direction. Gardening activities were negatively associated with the attitude of fresh versus packaged being important when purchasing food or beverages (p=0.018). Recycling activities were also significantly negatively associated with fresh versus packaged being important to the type of food or beverage being purchased (p=0.048). A significant negative association was also found between participation in Recycling activities and the Importance of local (p=0.024). Composting activities was not shown to be significantly associated 137 with any of the dietary attitudes, including the attitude of caring about the impact of food choices on the environment, or with the environmentally sustainable expectation outcome. 3.8 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days Similar to associations found between participation in SFNP activities and dietary attitudes and expectations, a limited number of significant associations were found between participation in activities and school day healthy and environmentally sustainable dietary choices and food practices. Furthermore, significant results were not always in the anticipated direction. Final results of associations measured between healthy and less healthy dietary choices are presented in Table 3-12. Results of environmentally sustainable, less environmentally sustainable and both less healthy and less environmentally sustainable dietary choices are presented in Table 3-13. Results of bivariate analyses between activity categories and food practices are presented in Table 3-14.138 Table 3-12 – Associations between participation in activity categories and healthy and less healthy dietary choices on school days (n=937) Dietary Choices Activity Category a No Yes g No Yes % % p i % % p Food preparation activities b Choosing or tasting healthy foods activities c Healthy Dietary Choice Item and Categories Vegetables Yes h 43 40 0.544 44 39 0.220 n 556 319 633 236 Fruit Yes 52 46 0.296 52 45 0.047 n 562 324 641 237 Vegetables or fruit Yes 66 59 0.116 65 59 0.143 n 565 325 644 238 Whole grains Yes 33 37 0.252 34 36 0.670 n 560 324 640 237 Low-fat milk or soy beverages Yes 50 40 0.007 47 45 0.611 n 551 316 623 236 139 Dietary Choices Activity Category a No Yes g No Yes % % p i % % p Food preparation activities Choosing or tasting healthy foods activities Healthy Dietary Choice Item and Categories Water Yes 80 76 0.256 78 81 0.406 n 559 325 640 237 Less Healthy Dietary Choice Categories Sugar-sweetened beverages Yes 32 29 0.357 31 29 0.544 n 559 321 639 234 Energy dense entrees or side dishes Yes 17 17 0.991 18 15 0.245 n 562 324 643 238 140 Dietary Choices Activity Category a No Yes g No Yes % % p i % % p Learning about Canada’s Food Guide d Learning about foods grown in British Columbia e Healthy Dietary Choice Item and Categories Vegetables Yes 42 44 0.560 41 45 0.336 n 461 374 535 293 Fruit Yes 50 50 0.874 48 51 0.484 n 464 377 540 295 Vegetables or fruit Yes 65 62 0.372 62 65 0.490 n 467 378 543 296 Whole grains Yes 33 36 0.508 / n 465 376 Low-fat milk or soy beverages Yes 45 46 0.803 / n 451 371 Water Yes 80 77 0.307 / n 463 379 141 Dietary Choices Activity Category a No Yes g No Yes % % p i % % p Learning about Canada’s Food Guide Learning about foods grown in British Columbia Less Healthy Dietary Choice Categories Sugar-sweetened beverages Yes 36 25 0.001 / n 463 374 Energy dense entrees or side dishes Yes 20 13 0.006 / n 466 379 142 Dietary Choices Activity Category a No Yes g % % p i Gardening activities f Healthy Dietary Choice Item and Categories Vegetables Yes 44 40 0.459 n 671 183 Fruit Yes 51 46 0.294 n 680 182 Vegetables or fruit Yes 64 62 0.638 n 682 184 Whole grains Yes 35 29 0.083 n 679 183 Low-fat milk or soy beverages Yes 46 45 0.773 n 662 179 Water Yes 79 78 0.922 n 678 184 Less Healthy Dietary Choice Categories Sugar-sweetened beverages Yes 32 26 0.058 n 675 182 Energy dense entrees or side dishes Yes 17 15 0.451 n 682 184 143 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" e The Learning about foods grown in British Columbia category refers to participation in the individual activity "Learning about foods grown in British Columbia" f The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own g "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. h "Yes" to dietary choice variables refers to the percentage of students who reported a frequency of ≥ once per day of an item for individual variables or a frequency of ≥ once per day of ≥ 1 item within a category for category variables. i P-value of Rao-Scott corrected chi-square test. Result significant for p < 0.05. / Activity categories not tested with outcome variables Note: Composting activities and Recycling activities not tested with Healthy and Less Healthy Dietary Choice Items or Categories. Therefore, results of bivariate analyses between these activities and these outcomes are not listed in table. 144 Table 3-13 – Associations between participation in activity categories and environmentally sustainable, less environmentally sustainable, and both less healthy and less environmentally sustainable dietary choices on school days (n=937) Dietary Choices Activity Category a No Yes i No Yes % % p k % % p Food preparation activities b Choosing or tasting healthy foods activities c Both Less Healthy and Less Environmentally Sustainable Dietary Choice Category Snack foods Yes j 22 17 0.090 21 17 0.204 n 567 326 647 238 Learning about Canada’s Food Guide d Learning about foods grown in British Columbia e Environmentally Sustainable Dietary Choice Category k Locally produced food (weekly) Yes / 56 64 0.050 n 542 297 145 Dietary Choices Activity Category a No Yes i No Yes % % p k % % p Learning about Canada’s Food Guide Learning about foods grown in British Columbia Both Less Healthy and Less Environmentally Sustainable Dietary Choice Category Snack foods Yes 23 17 0.052 22 17 0.136 n 468 380 545 297 146 Dietary Choices Activity Category a No Yes i No Yes No Yes % % p k % % p % % p Gardening activities f Composting activities g Recycling activities h Environmentally Sustainable Dietary Choice Items and Categories Food grown at a school (ever) Yes 20 30 0.094 / / n 669 178 Food that you helped grow (ever) Yes 49 57 0.059 / / n 670 183 Locally produced food (weekly) Yes 59 58 0.905 57 61 0.353 62 55 0.019 n 680 184 589 272 421 443 Food or beverages in recyclable or compostable packaging (weekly) Yes 45 42 0.399 44 46 0.556 45 44 0.779 n 666 180 574 269 411 435 147 Dietary Choices Activity Category a No Yes i No Yes No Yes % % p k % % p % % p Gardening activities Composting activities Recycling activities Less Environmentally Sustainable Dietary Choice Item Bottled water Yes 29 22 0.115 29 24 0.111 30 26 0.183 n 659 181 571 267 406 433 Both Less Healthy and Less Environmentally Sustainable Dietary Choice Category Snack foods Yes 21 17 0.319 19 22 0.257 20 19 0.625 n 685 183 593 272 425 444 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" e The Learning about foods grown in British Columbia category refers to participation in the individual activity "Learning about foods grown in British Columbia" f The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own g The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own h The Recycling activities category includes the following individual activities: Learning how to recycle, Recycling on my own 148 i "Yes" represents students who selected the response "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. j "Yes" refers to the percentage of students who reported intake of ≥ once per day (daily) of an item for individual variables or a total intake of ≥ once per day of any combination of items within a category for category variables. For variables labelled weekly, "Yes" refers to the percentage of students who reported intake of ≥ once per week (weekly) of any combination of items within a category for Environmentally Sustainable Dietary Choice Categories. For variables labelled ever, "Yes" refers to the percentage of students who reported intake > never (ever) for individual Environmentally Sustainable Dietary Choice variables labelled "(ever)". k P-value of Rao-Scott corrected chi-square test. Result significant for p < 0.05. / Activity categories not tested with outcome variables Note: Food preparation activities and Choosing or tasting healthy foods activities not tested with Environmentally Sustainable Dietary Choice Items and Categories or the one Both Less Healthy and Less Environmentally Sustainable Dietary Choice Category, and Learning about foods grown in British Columbia only tested with the following two Dietary Choice Categories: Locally produced food (weekly) and Snack foods. Therefore, results of bivariate analyses between these activities and other outcomes are not listed in table. 149 Table 3-14 – Associations between participation in activity categories and healthy and environmentally sustainable food practices on school days (n=937) Food Practices Activity Category a No Yes g No Yes % % p k % % p Food preparation activities b Choosing or tasting healthy foods activities c Healthy Food Practice Eat breakfast h Yes 62 58 0.258 60 62 0.697 n 560 321 640 235 Less Healthy Food Practice Item and Category Eat nothing for lunch (weekly) i Yes 15 13 0.594 16 10 0.002 n 555 320 636 234 Convenience food establishment purchasing (weekly) Yes 26 33 0.025 29 27 0.537 n 560 322 640 237 150 Food Practices Activity Category a No Yes g % % p k Learning about Canada’s Food Guide d Healthy Food Practice Eat breakfast Yes 61 61 0.855 n 462 377 Less Healthy Food Practice Item and Category Eat nothing for lunch (weekly) Yes 16 11 0.064 n 460 376 Convenience food establishment purchasing (weekly) Yes 29 27 0.451 n 465 377 151 Food Practices Activity Category a No Yes g % % p k Gardening activities e Healthy Food Practice Eat breakfast Yes 62 59 0.647 n 680 180 Less Healthy Food Practice Item and Category Eat nothing for lunch (weekly) Yes 15 14 0.828 n 676 180 Convenience food establishment purchasing (weekly) Yes 29 27 0.684 n 680 182 152 Food Practices Activity Category a No Yes g No Yes % % p k % % p Gardening activities Composting activities f Environmentally Sustainable Food Practice Items Eat food grown in neighbourhood/community (including school) (ever) j Yes 25 34 0.116 / n 663 178 Compost uneaten food at school (weekly) Yes / 11 15 0.202 n 572 269 a Activity categories include one individual activity or a combination of two or more individual activities listed in the following survey question: "Have you participated in any of the following this school year (anytime since September)? Choose all that apply." b The Food preparation activities category includes the following individual activities: Learning how to cook, Cooking on my own, Preparing healthy foods c The Choosing or tasting healthy foods activities category includes the following individual activities: Learning how to grocery shop, Grocery shopping on my own, Choosing healthy foods, Tasting healthy foods d The Learning about Canada’s Food Guide category refers to participation in the individual activity "Learning about Canada’s Food Guide" e The Gardening activities category includes the following individual activities: Learning how to grow food in a garden, Growing food in a garden on my own f The Composting activities category includes the following individual activities: Learning how to make compost, Composting on my own g "Yes" represented students who selected the response "Yes - At school (or as part of a school activity)" to participation in an individual activity or to participation in one or more individual activities combined in a category. h "Yes" to the variable Eat breakfast refers to the percentage of students who reported a frequency of ≥ once per day. i "Yes" to variables labelled "(weekly)" refers to the percentage of students who reported a frequency of ≥ once per week of an item for individual variables or a frequency of ≥ once per week of ≥ 1 item within a category for category variables. 153 j "Yes" to Eat food grown in neighbourhood/community (including school) (ever) refers to the percentage of students who reported any frequency > never. k P-value of Rao-Scott corrected chi-square test. Result significant for p < 0.05. / Activity categories not tested with outcome variables Note: Food preparation activities and Choosing or tasting healthy foods activities were only tested with Healthy and Less Healthy Food Practices. Therefore, results of bivariate analyses between these activities and Environmentally Sustainable Food Practice Items are not listed in table. Learning about foods grown in British Columbia and Recycling activities were not tested with Food Practices. Therefore, these activities are not listed in table. 154 All results of significant associations found between participation in Food preparation activities and dietary choices and food practices were in the unexpected direction. The only healthy dietary choice category to show a significant association with participation in Food preparation activities was intake of Low-fat milk or soy beverages (p=0.007). However, the association was in the negative direction. Furthermore, in terms of less healthy food practices, a significant positive association was found between the activity and Convenience food establishment purchasing (p=0.025). No other associations were found between Food preparation activities and the remaining healthy dietary choices or food practices. Choosing or tasting healthy foods activities revealed associations in both the expected direction and in the unanticipated direction. The activity was negatively associated with daily fruit intake on school days (p=0.047), but was also negatively associated of eating nothing for lunch (p=0.002). Participation in activities specific to learning about food or nutrition revealed either no associations with dietary behavioural outcomes or associations in the anticipated direction. Learning about Canada’s Food Guide was negatively associated with daily intake of Sugar-sweetened beverages (p=0.006) and daily consumption of Energy dense entrees or side dishes (p=0.001). Nevertheless, Learning about foods grown in British Columbia was not significantly associated with any dietary choice or food practice variables, including Vegetables or fruit. No associations were found between Gardening activities and dietary choices or food practices. In particular, Gardening activities was not associated with dietary intake of Vegetables, Fruit, or Vegetables or fruit. Furthermore, no associations were found between Gardening activities and environmentally sustainable dietary choices or food practices expected to directly relate to 155 participation in the activity, which included consumption of Local produced food (weekly), Food grown at a school(ever), Food that you helped grow (ever), and Eat Food grown in neighbourhood/community (including school) (ever). With respect to associations between participation in hands-on activities related to environmental sustainability, recycling and composting activities, only one association in the unexpected direction was found. Recycling activities was significantly negatively associated with weekly consumption of Locally produced food (p=0.019). Furthermore, no associations were found between recycling activities and remaining environmentally sustainable dietary choices or food practices, including the dietary choice reflecting environmentally sustainable packaging, Food or beverages in recyclable or compostable packaging. Composting activities was not found to show any significant associations with dietary choices or food practices, including the composting of leftover food at school. 3.9 Summary of Key Results 3.9.1 Participation in School Food and Nutrition Programs Results of participation in SFNPs revealed that less than half of students participated in individual SFNP activities or activity categories (with the exception of Recycling activities (51%). In addition, very few students participated in all activity categories at school this year, whereas many students reported that they had not participated in any activity category this school year. Results of participation in each activity category at each school showed that median school-level participation in SFNP activity categories was well below 50% for all activities, excluding recycling. Large differences in participation rates in each activity category were seen between schools and also between activity categories within schools. 156 Associations between participation in activity categories and gender and school type revealed significant differences. Results of participation in activities specific to learning about food or nutrition by gender revealed that females were significantly more likely to report participation in comparison to males. In addition, findings showed that secondary school students were significantly more likely to participate in food-specific activities (activity categories specifically related to healthy outcomes in addition to Learning about foods grown in British Columbia) compared to elementary school students. 3.9.2 Healthy and Environmentally Sustainable Dietary Attitudes and Expectations Over 50% of students reported positive responses to nearly all healthy and environmentally sustainable dietary psychosocial outcomes. Greater than 2/3 of students reported the importance of healthy or both healthy and sustainable dietary choices when making food purchases, with the highest percentage reporting the importance of healthy items (83%). In contrast, the proportion of students reporting the importance of environmentally sustainable dietary choices was lower, particularly for local items (42%). In addition, only approximately ¼ of students stated they cared “Very much” how food choices impact the environment. Over half of students agreed with dietary expectations that food choices affect health or the environment, with a greater percentage selecting agreement with “affect health”. 3.9.3 Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days Results of dietary choices revealed that less than 50% of students reported daily intake of many healthy dietary choices, including Vegetables and Low fat milk or soy beverages, and weekly intake of individual or categories of environmentally sustainable or less environmentally sustainable dietary choices, with the exception of Locally produced food. However, the percentages of students 157 who stated they consume less healthy, less environmentally sustainable or both less healthy and less environmentally sustainable choices daily were lower compared to healthy choices. In terms of food practices, the majority of students reported healthy food practices, whereas less than the majority of students reported less healthy or environmentally sustainable food practices. In particular, nearly 40% of students reported not eating breakfast daily on school days, whereas 14% stated they miss lunch (Eat nothing for lunch) at least once per week. Slightly less than 1/3 of students reported weekly purchasing from one or more convenience food establishments. Very few students reported eating food grown in their neighbourhood/community or composting uneaten food at school on a weekly basis. 3.9.4 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Attitudes and Expectations Both participation in SFNP activities specific to learning about food or nutrition, including Learning about Canada’s Food Guide and Learning about foods grown in British Columbia, demonstrated positive associations with the healthy dietary attitude regarding the importance of fresh vegetables when making food purchases on school days. In addition, both activities showed positive associations with healthy or environmentally sustainable dietary expectations. Table 3-15 presents a summary of all significant associations found between participation in activities and dietary psychosocial and behavioural outcomes.158 Table 3-15 – Summary of significant associations between activity categories and healthy and environmentally sustainable dietary psychosocial and behavioural outcomes (n=937) Activity Category Healthy Dietary Attitudes Environmentally Sustainable Dietary Attitudes Both Healthy and Environmentally Sustainable Dietary Attitudes Healthy Dietary Expectations Environmentally Sustainable Dietary Expectations Food preparation activities Choosing or tasting healthy foods activities Learning about Canada’s Food Guide (+) a Importance fresh vegetables (+) Food choices - agree affect health Learning about foods grown in British Columbia (+) Importance fresh vegetables (+) Food choices - agree affect environment Gardening activities (-) Importance fresh vs. packaged Composting activities Recycling activities (-) Importance local (-) Importance fresh vs. packaged 159 Activity Category Healthy Dietary Choices Less Healthy Dietary Choices Environmentally Sustainable Dietary Choices Less Healthy Food Practices Food preparation activities (-) b Low fat milk or soy beverages (daily) c (+) Convenience food establishment purchasing (weekly) d Choosing or tasting healthy foods activities (-) Fruit (daily) (-) Eat nothing for lunch (weekly) Learning about Canada’s Food Guide (-) Sugar-sweetened beverages (daily) (-) Energy dense entrees or side dishes (daily) Learning about foods grown in British Columbia Gardening activities Composting activities Recycling activities (-) Locally produced food (weekly) a (+) Symbol represents a positive association between participation in the activity category and the outcome variable b (-) Symbol represents a negative association between participation in the activity category and the outcome variable c "(daily)" refers to students who reported a frequency of ≥ once per day of an item for individual variables or a total frequency of ≥ once per day of any combination of items within a category for category variables d "(weekly)" refers to students who reported a frequency of ≥ once per week of an item for individual variables or a frequency of ≥ once per week of ≥ 1 item within a category for category variables Note: No associations found between participation in activity categories and the Less Sustainable Dietary Choice or the Both Less Healthy and Less Environmentally Sustainable Dietary Choice, or Environmentally Sustainable Food Practices. Variables were therefore not included in table. 160 Participation in SFNP hands-on activities revealed only associations in the unexpected direction with dietary psychosocial outcomes. Both gardening and recycling activities revealed a negative association with the both healthy and environmentally sustainable dietary attitude of the importance of food being fresh versus packaged when making purchases on school days. Recycling activities also showed a negative association with the environmentally sustainable attitude towards the importance of the food being local when making food or beverage purchases on school days. Composting activities and the two SFNP hands-on activities related to healthy outcomes, Food preparation activities and Choosing or tasting healthy foods activities, showed no associations with dietary psychosocial outcomes. 3.9.5 Associations between Participation in School Food and Nutrition Programs and Healthy and Environmentally Sustainable Dietary Choices and Food Practices on School Days In terms of results of associations between SFNP activities specific to learning about food or nutrition and dietary behavioural outcomes, only Learning about Canada’s Food Guide showed significant associations, which were found in the expected direction. Learning about Canada’s Food Guide was negatively associated with the less healthy dietary choices, Sugar-sweetened beverages and Energy dense entrees or side dishes. The SFNP hands-on activities related to healthy psychosocial and behavioural outcomes, which included Food preparation activities and Choosing or tasting healthy foods revealed both expected and unexpected associations with dietary behavioural outcomes. Both activities showed negative associations with healthy dietary choices. However, the activities also showed either positive or negative associations with less healthy food practices. 161 Results of associations between SFNP hands-on activities related to environmental sustainability and dietary behavioural outcomes showed that Recycling activities was negatively associated with the environmentally sustainable dietary choice of Locally produced food. However, participation in Composting activities showed no associations with dietary choices or food practices.162 Chapter 4: Discussion As few studies have evaluated participation in school food and nutrition programs or healthy or environmentally sustainable dietary psychosocial or behavioural outcomes specific to school days, or associations between participation in SFNPs and healthy or environmentally sustainable outcomes, this study contributes new findings to these areas of research. However, in light of the limited research evaluating participation in SFNPs and associations with school day healthy or environmentally sustainable outcomes measured, the present study was restricted in its ability to compare results to previous findings in this area of research. In particular, there do not appear to be previous estimates of student participation rates in SFNPs within or outside Vancouver with which to compare results. 4.1 Participation in School Food and Nutrition Programs 4.1.1 Student-Level Participation in Individual and Categories of SFNP Activities Reported participation in SFNPs indicates that less than half of students participated in individual SFNP activities or in combined activity categories (with the exception of recycling activities) this school year. Furthermore, results revealed that some students had no opportunities to participate or did not engage in activities this school year, and that very few students participated in all activities. These findings suggest that a limited number of students participated in learning about food and nutrition, in addition to a combination of activities to represent various components of the food system cycle, from production to disposal. Results therefore indicate a potential opportunity to increase participation in SFNP activities and activity categories among Gr.6-8 students in Vancouver schools. Yet, due to current knowledge of the variety and widespread integration of activities in Vancouver that were evaluated, results of participation rates were anticipated to reveal higher percentages. 163 The result that less than half of students reported participation in all individual activities, including both recycling activities, was important to note, as it indicates that the majority of students in Vancouver in grades 6-8 are not participating in the individual SFNP activities evaluated. In particular, though it was not surprising that Learning how to recycle was the most highly reported activity, as one would expect that most students would be taught how to use or would independently use the school recycling bins anticipated to be located in most schools, it was expected that a higher proportion of students would have reported participation in recycling activities, due to the district-wide recycling program in Vancouver schools. Nevertheless, this result suggests that recycling is the most widespread SFNP activity available within Vancouver. The finding that the activity reported the least frequently was Grocery shopping on my own, suggests that students most likely have limited opportunities to grocery shop during the school day, particularly at schools where students are not given permission to leave the school grounds during the day. The finding that rates of participation in individual SFNP activities, where students learn about the activity, was higher than the percentage of students who reported participating in the activity independently (“on my own”) indicates that students are more frequently exposed to activities through lessons, than through independent activities. Several reasons may potentially have contributed to these results. For example, students may participate less frequently in activities independently if they are not permitted to participate without supervision, or if they lack self-efficacy in completing the activity without assistance from teachers or class peers. Students may also be less likely to engage in activities by themselves if they are not interested in participating in the activity outside of a class lesson plan. Furthermore, students may not yet have the skills necessary to perform the activity independently. For instance, composting 164 activities may require strength or height to transport and mix organic waste in school bins, which may be difficult for some students without assistance from another individual(s). Among healthy dietary related individual activities, Learning about Canada’s Food Guide was the activity most frequently reported among the activities, suggesting that Canada’s Food Guide is frequently incorporated into the curriculum. This result also supports the expectation that lessons teaching about Canada’s Food Guide are often integrated into curriculum subjects related to health or food and nutrition, such as Health and Career Education Grade 6 (British Columbia Ministry of Education, 2006). However, though one might anticipate that activities involving preparing or tasting healthy foods to be incorporated into cooking activities, compared to the proportion of students that reported participating in Learning how to cook, approximately half as many students reported participating in the individual activities of Preparing healthy foods or Tasting healthy foods. This result may indicate that cooking, as part of food preparation activities, is often perceived by students as a skill-based activity and not specific to the preparation or tasting of healthy foods. In addition, it may also be possible that some school food preparation activities do not involve a large proportion of healthy recipes. For example, if students are learning methods for preparing muffins or biscuits, they may be preparing baked items that would seem less healthy to students in comparison to other recipes, such as a vegetable pasta or vegetable based soup. In comparison to recycling activities, a much lower percentage of students participated in the remaining environmentally sustainable activities which related to composting. The result that less than 1/3 of students reported participation in Learning how to make compost, indicates that engagement or opportunities to participate in composting activities are much lower than opportunities to participate or involvement in recycling activities. This result is most likely 165 related to the fact that at the time of this study, in comparison to the presence of district-wide recycling, district-wide composting was not available. The availability of composting activities would therefore be expected to depend on whether school administration or teachers were interested in implementing compost bins and/or in integrating composting activities into their school curriculum. With regard to participation in individual activities reflecting both health and environmental sustainability, the result that Learning about foods grown in British Columbia was the fourth most highly reported of all individual activities, may potentially be related to student involvement in the BC School Fruit and Vegetable Program and/or to curriculum discussing environmental sustainability and the potential positive environmental impacts of local food production. However, surprisingly, despite visible school gardens in place at schools participating in the study (direct observations during schools visits, and communications with Think&EatGreen@School research team members and community co-investigators, 2012), less than one quarter of students reported participation in school Gardening activities. This finding indicates that a limited number of students are gaining the opportunity to or are choosing to participate in gardening activities in Vancouver schools. In addition, as students were asked specifically about participation in growing food in a garden, there also remains the possibility that students who participated in a school garden were participating in other gardening activities that do not involve growing food, such as doing artwork, learning about soil or insects, or growing non-edible plants. Students who did not report participation in Gardening activities may also have been growing food in other locations at school (other than in a garden), such as in classroom window box planters or in buckets or tubs. This finding, however, is supported by the article published on Canadian school food and eating environments, which found that the healthy 166 eating education item reported as being offered by schools the least was gardening activities (15%), though student participation rates in gardening activities was not specifically investigated (Browning et al., 2013). The result in the present study that very few students reported gardening on their own at school, may be an indication that very few students in grades 6-8 are provided with the opportunity to garden at school when not under direct supervision by a school teacher or staff member. After combining individual activities into categories, with the exception of recycling, overall reported participation rates in activity categories, as for individual activities, was less than 50%. Due to the numerous SFNP activities available throughout VSB schools, it was unexpected that 20% of students would report not participating in any activity category this year. The overall finding that very few students reported participating in all seven activity categories may indicate that students do not receive the opportunity to learn about healthy eating and locally produced foods, and to also engage in hands-on activities reflecting various components of the food system cycle, from food production, to preparation, consumption, and disposal. Previous research or reports have indicated a potential benefit of participation in a combination of SFNP activities on student dietary outcomes, including food and nutrition education and activities representing the food system cycle, such as the Fresh from the Farm program (Kish, 2008). As previously introduced, the Fresh from the Farm program included education on the benefits of consuming food that is fresh, local and organic, on health and the environment, as well as opportunities for students to engage in planting, harvesting and composting on a farm, and to taste fresh vegetables and fruits (weekly). Assessment of program outcomes revealed an increase in understanding of the importance of consumption of fresh vegetables and fruit among students, as well as increased student dietary intake of healthy foods (Kish, 2008). 167 4.1.2 School-Level Participation in SFNP Activity Categories With the exception of recycling, overall median school participation rates in each activity category were less than 50%, indicating that the majority of students in schools are not participating in most SFNPs evaluated. In addition, descriptive results of participation rates in each activity category among schools showed variability in participation in each activity between schools and in participation between activities within schools. These findings therefore suggest that opportunities for participation in SFNP activity categories may be limited in some schools in comparison to others. These results, however, were expected due to anticipated differences between schools in aspects such as curriculum and the physical environment (including teaching facilities). For example, individual teachers may be interested in integrating different activities into their classrooms based on their knowledge of specific activities, as well as the curriculum subject they are teaching (personal communications with VSB staff, 2013). Results of participation rates in activity categories among and within schools therefore provide evidence to support increased opportunities for and encouragement of participation in most SFNPs in the majority of schools, particularly in schools where reported participation in most activity categories is low. In comparison to other activities, where availability of activities was expected to vary depending on the specific school environment and staff, due to the implementation of district-wide recycling, it was unexpected that participation in Recycling activities would differ between schools, as recycling was expected to be relatively equally available in the majority of Vancouver schools. However, some schools revealed much larger participation rates in recycling activities in comparison to others, indicating that students in some Vancouver schools are more engaged in recycling activities compared to students in other schools within Vancouver. The 168 reported differences may have arisen from students first learning how to recycle in different grades at each school, and not necessarily being taught about recycling in subsequent school grades. Once students are provided lessons on recycling at school they may be expected to have the appropriate knowledge and skills to take on the responsibility of recycling their items at school each day, and are therefore not taught about recycling in future school years. Furthermore, overall participation in recycling activities may differ based on variability in student participation in Recycling on my own, based on individual student interest in recycling at each school. For example, some schools may have programs or strategies in place to encourage Recycling on my own, which may increase independent classroom recycling among students at certain schools. Comparable to the large variation observed in participation rates between schools, descriptive results revealed that variability also existed among the proportion of students participating between each activity within each school. The potential reasons to explain the differences observed in reported participation in activities between schools, may also help to explain the variability seen in participation between activities within schools, including possible differences in how SFNPs are integrated into the curriculum at each school, and differences in the specific activities chosen by administrators or teachers to be applied towards meeting curriculum goals. Though evaluation of participation in SFNP activities outside of school was not included as part of the study objectives, students did report participation in individual SFNP activities and activity categories in various locations outside of school. Results of participation in individual activities, both to no participation and to participation in different locations outside of school in each individual activity, as well as to participation in each individual activity in any location 169 outside of school, are presented in Appendix F. Findings of participation in activity categories in any location outside of school and to no participation in each activity category are presented in Appendix G. Results indicated that a high prevalence of students participated in activities outside of school, with a large percentage of students engaging in activities at home. This potentially indicates that students have more opportunities to engage in activities independently in the community setting without direct supervision, in comparison to when students are at school. The only activities (both individual and categories of activities) that showed a higher proportion of participation at school compared to outside of school were for the individual activities Learning about Canada’s Food Guide and Learning about foods grown in British Columbia. This result was most likely due to the greater opportunities for students to engage in activities specific to learning about food or nutrition in a school classroom setting as part of the curriculum. 4.1.3 Differences in Participation in SFNP Activities by Gender and School Type Results of participation in SFNPs by gender and school types also indicate that differences exist in participation between these student groups. Findings revealed that females may be more likely to participate or report participation in activities specifically focussing on learning about food or nutrition, indicating an opportunity to further promote participation in these activities among male students. In addition, participation rates in healthy food-specific activity categories were shown to be greater among secondary school students in comparison to elementary school students, indicating a potential to increase participation in these activities within Vancouver elementary schools. The significant difference found between genders for participation in both Learning about Canada’s Food Guide and Learning about foods grown in British Columbia, suggests that 170 girls are more likely to participate in activities specific to learning about food or nutrition compared to boys. With the exception of Choosing or tasting healthy foods (where percentages were similar), girls also reported higher participation compared to males for remaining activities, though not significant. Nevertheless, there was no priori reason to believe that opportunities to participate in the learning activities specific to food or nutrition would differ between males and females, as activities were not anticipated to be voluntary but were expected to be included in the school curriculum and therefore delivered equally to all students in the same grade. Previous research on gender differences in participation in recycling and food preparation activities among youth also showed greater reported participation among females in activities compared to males, but results were significant in comparison to results in the present study. In the study by Zelezny (1998), investigating participation in school recycling, on a scale from “never” to “very often” the author found that the mean participation among girls (3.31) was significantly higher compared to boys (2.91) following implementation of the school recycling program. However, different to the study by Zelezny (1998), which evaluated frequency of participation, participation rates in the present study represented students who reported participation to any extent, “participants”, in comparison to students who had not reported participation, “non-participants”. Therefore, as rates in the present study do not indicate frequency of participation, findings between these two studies are not directly comparable. In addition, in the article by Woodruff & Kirby (2013), authors did find a significant difference in reported food preparation techniques between genders. In comparison to boys, girls were found to have a larger range of food preparation techniques (6.9 vs. 5.7, P=0 .02) (Woodruff & Kirby, 2013). Nevertheless, similar to the current study, which showed no significant difference in participation in food preparation activities between genders, authors did not find a significant 171 difference between genders in the reported frequency of participation in food preparation over the previous seven days. Overall, however, findings in the current study, as well as in the studies by Zelezny (1998) and Woodruff & Kirby (2013), suggest a potential gendered dimension in reported participation between genders, where females may be more likely to participate or report participation in certain SFNP activities compared to males. As anticipated, due to the likely integration of Home Economics: Foods and Nutrition 8, as part of the required grade 8 curriculum for the majority of secondary schools in the VSB, results of participation in activities by school type revealed that participation in activities specifically working with food or learning about food or nutrition (food-specific) was significantly higher among secondary school students. Similar results were found in the study by Woodruff & Kirby (2013) investigating participation in food preparation, which revealed significantly higher participation among older grades (grades 7-8 vs. 4-6). However, as results in the article appeared to reflect general participation in food preparation (Woodruff & Kirby, 2013), and authors did not comment on whether participants in older grades were expected to have had an opportunity to participate in school food preparation activities, it was not possible to establish whether higher participation among older grades resulted from greater involvement in food preparation activities at school. Results were also supported by the article by Browning et al. (2013) which revealed a significant difference (P < 0.001) in the offering of cooking classes between primary (33.0%), mixed (83.0%) and secondary (77.1%) schools, showing a higher percentage among mixed and secondary schools in comparison to primary schools. Though percentages in the article represented the number of schools who offered cooking activities, and not student reported participation, the findings in the present study were similar in showing 172 higher reported participation rates in Food preparation activities among students in secondary school in comparison to students in elementary school. In contrast to participation in food-specific activities, though not significant, participation rates in gardening and composting activities were higher among elementary school students. The reason for a greater number of student participants in elementary versus secondary school may be in part related to potential greater flexibility among elementary school teachers to integrate hands-on SFNPs related to environmental sustainability or both health and environmental sustainability into the school grade curriculum (personal communications with VSB and Think&EatGreen@School co-investigators, 2012-2013). There is also a possibility that a higher number of school gardens or compost systems have been implemented in Vancouver elementary schools compared to secondary schools. Though only investigating the offering of gardening activities in schools, the article by Browning et al. (2013) also reported similar results to the present study, showing a non-significant difference in participation between primary, mixed, and secondary schools, but also revealing a higher participation in primary schools (14.8%) or mixed schools (17.9%) in comparison to secondary schools (12.8%). Therefore, results of this article may also support the possible reasons described for findings found in this study, of the potential increased difficulty in integrating gardening activities into the curriculum among secondary schools in comparison to integration among elementary schools. Participation rates were similarly reported between elementary and secondary schools for Recycling activities, which most likely reflects the implementation of district-wide recycling and expected fairly equal opportunities among elementary and secondary school students to recycle at school. However, this result was not consistent with findings in the study by Zelezny (1998), comparing elementary, intermediate, and high school students, which found a significant 173 difference between school types following the recycling program. Results revealed that mean participation was higher among elementary school students compared to intermediate and secondary school students (Zelezny, 1998). However, compared to the present study, where the majority of elementary school participants were in grade 7, and most likely similar in age to the grade 8 student participants in secondary school, the study by Zelezny (1998) compared students separated by a greater number of grades (students in grades 6,8,11 surveyed after district-wide recycling implementation).Therefore, as participants in the current study were most likely closer in age compared to students in the study by Zelezny (1998), this might have been an important factor in the similarity in reported participation in recycling found between school types in the present study. 4.2 Healthy and Environmentally Sustainable Dietary Attitudes With respect to dietary attitudes, with the exception of local, the majority of students indicated that items considered either healthy, environmentally sustainable, or both, were important towards decisions regarding food or beverage purchases on school days. These results show a potential trend towards the importance of these types of items among students in Vancouver when making dietary purchases on school days. However, the result that a much lower percentage of students reported the attitude of caring “Very much” how food choices impact the environment may indicate that the reported importance of the environmental sustainability or both the health and environmental sustainability of items when making school day food or beverage purchases may not reflect an overall concern for the environmental impact of food choices. Results specific to healthy dietary attitudes towards food purchasing on school days, showed that the majority of students reported healthy dietary attitudes. Though results from this 174 study revealed slightly higher percentages compared to previous research, results were consistent with earlier studies showing that the majority of participants report healthy dietary attitudes. In comparison to the present study, which showed that 69% of students reported that fresh vegetables are an important factor to school day purchases, in the study by Gosliner et al. (2011) investigating the importance of purchasing specific food items at school, a lower percentage of students rated other vegetables as important (53%) and green salad as important (55%). However, as the article by Gosliner et al. (2011) asked specifically about attitudes towards purchases made only at school, while the current study referred to any purchases made on school days, there remains a possibility that attitudes would differ based on the purchasing location. Nonetheless, the present study and the study by Gosliner et al. (2011) both indicate that the majority of students report the importance of fresh vegetables or general vegetables when making dietary purchases either at school or on school days. Results from the present study also indicate that overall healthfulness of food may be important to students. The finding that greater than 80% of students reported that “healthy” was an important factor when making food purchasing decisions on school days was similar to the result in the study by Bissonnette & Contento (2001), which showed that 83.9% of students rated healthfulness of food as important to them. The authors also reported that 60.9 % of participants identified themselves as being health conscious (Bissonnette & Contento, 2001). The findings from the current study, as well as the study by Bissonnette & Contento (2001), suggest the potential importance of the concept of following a “healthy lifestyle” among adolescents, including the consumption of healthy dietary choices. 175 With regard to results of the importance of local when making food purchases on school days, in comparison to the present study, revealing that slightly less than half of students (42%) reported the importance of local dietary choices, in the study by Robinson-O'Brien, Larson et al. (2009), using data collected from the Project EAT-II study conducted in Minnesota, the percentage of participants who reported locally grown as somewhat or very important to their food was much lower (20.9%). However, in comparison to the present study, which evaluated school day attitudes, attitudes measured in the study Robinson-O'Brien, Larson et al. (2009) were not directly related to food and beverage purchases on school days. Therefore, it is not possible to establish whether school day attitudes would have differed from general attitudes measured. Furthermore, it is important to consider differences between the social and environmental contexts between study locations, and changes to attitudes which may have occurred over time between the years these two studies were conducted (personal communication with research team member, 2014). The result showing a much lower proportion of students reporting a positive attitude towards caring about how food choices impact the environment compared to the positive attitude reported among students towards purchasing environmentally friendly items on school days, may have resulted from either or both a difference in the response options and consumer role. In comparison to the dichotomized response options for purchasing attitude variables, which compared students who agreed that it was “Important” to any extent to those who were neutral or did not agree, the variable reflecting students’ level of caring towards the impact of food choices was dichotomized based on students who selected that they cared “Very much” compared to those who selected “A little bit” “Somewhat” or “Not at all”. Therefore, caring “Very much” potentially represented a stronger response statement in comparison to the response category of 176 “Important” to any extent. However, the findings may also be partly explained by the discussion of similar results found in the article by Bissonnette & Contento (2001), explaining that “more teens responded in the familiar role of consumer, expressing the right of access to organically and locally grown foods, than in the role of citizen concerned about how or where food is grown.” (p. 78). The study by Bissonnette & Contento (2001) showed that though 66.2% reported that “people should have more locally grown foods available to them”, 80% of participants reported that “it was not important to them personally that food is grown nearby.” (p. 75). Therefore results of the present study may indicate that students believe that they should have foods available and freedom of choice as a consumer, though they may not necessarily be concerned overall with the environmental implications of their food choices. In comparison to other dietary school day purchasing attitudes, including whether items are environmentally friendly, fewer students reported the importance of local items. These results suggest that whether food or beverage items being purchased are local is not as important to students as other factors, such as whether the item is “healthy” or “minimally processed”. Similar to the discussion of results of the importance of “healthy” items in the present study, there is a possibility that these findings resulted from the fact that the general concept of “environmentally friendly” or environmentally sustainable is important towards food purchasing decisions among students, but not necessarily a particular food type. These results were similar to findings in the article by Bissonnette & Contento (2001), where 57.6% of respondents indicated that they self-identified as being environmentally concerned. However, only 41.3% indicated (strongly or somewhat agreeing) “that they should buy more locally grown foods in order to improve the health of the environment.” (perceived responsibility) (Bissonnette & Contento, 2001, p. 75). However, results in the present study may also indicate a potential perception among students 177 that “local” does not always equate to an “environmentally friendly” or sustainable choice. As will be discussed in relation to results of bivariate analyses, there are also additional factors which may have influenced results of attitudes towards the importance of types of dietary items to student school day purchases (including local items), such as item availability. Nevertheless, similar to the potential reasons described for results of healthy dietary attitudes, as students were asked specifically about food purchasing on “school days” in the present study, whether the item is local may not be a key consideration to students when making food purchases on school days if local items are consumed at other occasions during the day. The majority of students reported the importance of both healthy and environmentally sustainable food or beverage items towards school day purchases, such as fresh versus packaged and minimally processed (>70%). This result, in addition to results of purchasing attitudes reflecting healthy or environmentally sustainable items, indicates a potential overall trend in positive attitudes towards healthy and environmentally sustainable school day dietary purchases among Vancouver students in grades 6-8. However, results of the attitude towards minimally processed school day food or beverage purchases revealed a higher percentage compared to the finding that only 29.8% stated that non-processed was somewhat or very important to their food in the study by Robinson-O'Brien, Larson et al. (2009). The difference in results in the present study compared to the study by Robinson-O'Brien, Larson et al. (2009) might have partly been related to the fact that the current study was specifically evaluating food or beverage purchasing attitudes, and only on school days. Other possible factors to explain differences in the findings found between studies include differences in the school environments (including policies), as well as differences in societal trends towards dietary choices and food practices that reflect both 178 health and environmental sustainability (personal communication with research team member, 2014). 4.3 Healthy and Environmentally Sustainable Dietary Expectations As the majority of students agreed with the dietary expectation that food choices affect health or the environment, this indicates a possible awareness among students of the potential impacts of dietary choices on health and environmental sustainability. Nevertheless, the result that a much lower percentage of students reported the attitude of caring “Very much” how food choices impact the environment may suggest that despite student expectations of the environmental implications of food choices, this expectation may not translate into a concern for the impact of food choices on the environment. Fewer students agreed with the expectation that food choices affect health compared to the majority of students stating that “healthy” was an important factor in making food purchasing decisions. This finding may potentially be related to a lack of awareness that food can have a direct impact on health, whereas students may feel that the concept of “healthy” is a good guideline to follow when making dietary choices in order to support the concept of an overall healthy lifestyle. The proportion of students who indicated that they cared about “How food choices impact the environment” was approximately half the proportion of students who agreed with the expectation that food choices affect the environment. This result may possibly reflect a perception among students that caring is related to an interest in or a concern towards environmental issues, whereas, in contrast, agreement with the statement that food choices affect 179 the environment may be perceived as an indication of knowledge and awareness of the environmental impacts of food systems and dietary choices. 4.4 Healthy and Environmentally Sustainable Dietary Choices on School Days Results of reported dietary choices revealed that the majority of students did not report daily intake of most healthy choices or weekly intake of most environmentally sustainable dietary choices. Intake of many healthy dietary choices, including vegetables and low-fat milk or soy beverages, was ≤ 50%, indicating a potential ability to increase school day intake of healthy dietary choices among students. Though smaller percentages of students reported daily consumption of less healthy, less environmentally sustainable or both less healthy and less environmentally sustainable choices in comparison to healthy dietary choices, there is still a possibility to further reduce the frequency of intake of less healthy, less environmentally sustainable, or both less healthy and less environmentally sustainable items on school days. Excluding the overall dietary choice category of Locally produced food, as less than half of students reported weekly intake of environmentally sustainable dietary choices, this suggests a potential to further promote and support school day intake of environmentally sustainable dietary choices. Though a large proportion of participants reported positive healthy dietary attitudes and expectations, results revealed that less than or equal to half of students reported daily consumption of several healthy dietary choices on school days: vegetables, fruit, whole grains, and low-fat milk or soy beverages. As students typically consume a large portion of their calories during the school day, this finding indicates that many students may not be meeting Eating Well with Canada’s Food Guide recommendations (Health Canada, 2007a), which is consistent with findings from CCHS 2.2 (Garriguet, 2004). Results from CCHS 2.2 revealed that a large 180 percentage of youth in Canada are not meeting current dietary intake recommendations for milk products, and vegetables and fruit (Garriguet, 2004). Results indicated that 83% of girls and 61% of boys between the ages of 10 to 16 are not consuming minimum recommendations for milk products (3 servings per day). Furthermore, 62% of girls and 68% of boys between the ages 9 to 13 are not consuming minimum recommendations for vegetables and fruit (5 servings per day) (Garriguet, 2004). Results indicated that the frequency of daily intake of less healthy choices among students is much lower compared to the intake of healthy choices. For example, in comparison to healthy choices such as low-fat milk or soy beverages and water, sugar-sweetened beverages were much less frequently consumed on a daily basis. However, these results were different from previous research investigating school day dietary choices which found greater reported intakes of less healthy food items compared to healthy items among adolescents. For example, the article by McDuffie & George (2009) revealed that during a five day period, consumption of all nutrient-dense foods were reported less than twice among students and less than energy-dense foods. In addition, in the study by Woodruff et al. (2010), investigating dietary intake at lunch among adolescents, the percentage of students who reported intake of “sugarsweetened” beverages (46%) was higher during lunch alone compared to the percentage of students who reported consumption of sugar-sweetened beverages at anytime on school days in the present study (31%). These two studies suggest an overall lower frequency of intake of school day less healthy dietary choices among grade 6-8 students in Vancouver in comparison to other previously investigated student populations. One potential reason for the result showing a lower frequency of intake of less healthy dietary choices compared to healthy dietary choices compared to previous research, may be 181 related to specific characteristics of Vancouver schools. For example, due to the BC Guidelines, students in the present study may have had greater availability of healthy dietary choices and limited to no availability of less healthy choices, including sugar-sweetened beverages, while attending school. Furthermore, as many schools included in this study offered a school lunch program (personal communications with VSB staff, 2012), intake of healthy dietary choices compared to less healthy choices may have been higher among students in this study compared to previous research, due to student participation in a school meal program. Lastly, the limited opportunities among many Vancouver elementary school students to leave the school grounds during the school day to purchase additional food and beverages, may have further reduced intake of less healthy dietary choices among the sample of students. Therefore, environmental factors, such as school lunch programs and the BC Guidelines, as well as limited opportunities to purchase food outside of the school setting among elementary school students, may be helping to encourage intake of healthy items and limiting consumption of less healthy items among Vancouver students, in comparison to other school districts where these policies, and/or lunch or breakfast programs, may not be present. This discussion is supported by the conclusions in the study by Woodruff et al. (2010) stating that “findings support schools in policy efforts that restrict fast food access (by leaving school grounds, preventing fast food companies from coming onto school grounds, or restricting sugar-sweetened beverage sales in vending machines)” (p. 427). Though only 42% reported the importance of local items when making food or beverage purchases on school days, over half of students reported consuming Locally produced food on a weekly basis. This indicates a potential awareness about local food among students, as well as a potential attention to the consumption of local foods. This result also indicates that local foods 182 may often be available and accessible in schools, in the surrounding neighbourhoods, or at home, in order for students to be consuming local items at least once per week on school days. The result that approximately half of students reported that they had “Ever” consumed Food that you helped grow, compared to less than a quarter of students recalling “Ever” consuming Food grown at a school, suggests that students are potentially gaining opportunities to grow food and consume these foods outside of school. This finding is also supported by the results of participation in SFNP categories revealing that a greater percentage of students participated in gardening activities outside of school compared to at school. Nevertheless, overall results showing that only 22% of students “Ever” consuming Food grown at a school, indicates that few students in Vancouver in grades 6-8 are engaging in opportunities to taste foods grown on school grounds/property. The result that slightly less than 50% of students reported weekly intake of Food or beverages in recyclable or compostable packaging suggests that this may not be a key consideration to student dietary choices on school days. However, results do not necessarily indicate that students are not concerned with the environmental sustainability of dietary choices in terms of packaging. For example, results may be in part due to a lack of awareness among students as to whether the packaging is recyclable or compostable. The finding may also reflect a lack of availability of these forms of packaging among students on school days, particularly if students are not involved in the decision-making regarding the packaging used for their school day dietary choices both either at school or outside of school, in the case when dietary items are typically provided by others. Furthermore, there is also the potential that many students are using reusable containers. The use of reusable containers would still represent an environmentally sustainable option as per recommendations provided by Environment Canada (2013) regarding 183 pollution prevention at school. However, students would not need to dispose of these containers through recycling or composting. As was discussed for results of dietary intake of less healthy dietary choices, the low percentage of students reporting daily consumption of Bottled water or Snack foods compared to healthy items may have resulted from decreased availability of these items while at school, or limited opportunities to purchase snack food items during school hours, particularly among elementary school students where schools often do not grant permission for students to leave the school during school hours (personal communications with Think&EatGreen@School research team members, 2012). As the BC Guidelines coincide with recommendations from Canada’s Food Guide (Health Canada, 2007a) regarding lower dietary intake of fat, salt and sugar for those greater than age two (British Columbia Ministry of Education & British Columbia Ministry of Healthy Living and Sport, 2010), the availability of many snack food items, such as candy, chocolate bars, and salty potato chips, would be expected to be limited at schools in Vancouver, due to their high fat, salt and/or sugar content. Furthermore, bottled water and snack foods may be provided more often at schools that supply vending machines for student use. However, unlike secondary schools in Vancouver, elementary schools do not typically have vending machines (personal communications according to Think&EatGreen@School research team members and community co-investigators, 2012) which would supply bottled water. Therefore, as the majority of the study sample consisted of elementary school students, the lower consumption of snack foods and bottled water among students in the sample may have been in part due to availability in elementary schools. 184 4.5 Healthy and Environmentally Sustainable Food Practices on School Days Results of food practices reveal that an opportunity exists to further increase healthy and environmentally sustainable food practices and to decrease less healthy food practices among Vancouver students in grades 6-8. Reported intake of daily breakfast, and eating nothing for lunch at least once per week, indicates that many students may frequently miss one or more meals during a school week. Furthermore, results of weekly purchasing from convenience food establishments, suggest that though the BC Guidelines and school meal programs are in place to help ensure that dietary choices provided in schools are healthy options, many students may be purchasing less healthy options outside of the school setting on school days. As a limited number of students reported “Ever” eating food grown specifically in their neighbourhood/community (including school), or composting uneaten food at school at least once per week, these findings indicate that few occasions for students to engage in environmentally sustainable food practices on school days may currently exist. A similar percentage of students reported that they “Never” Eat nothing for lunch (indicating they always eat dietary items for lunch on school days) compared to those that indicated they eat breakfast once a day (Monday through Friday). Results therefore indicate that close to at least 40% of students reported missing either lunch, breakfast or both in a typical month. Though results suggest that some students do not always have food available for breakfast or lunch meals on school days, many students could often be missing meals on occasion out of choice, such as missing breakfast if they are running late for school classes to start, or some students may choose to skip lunch when participating in a hands-on school club that takes place during the lunch hour once a week. Nonetheless, findings related to the consumption of breakfast and lunch on school days, assists in providing one potential factor that 185 may be contributing to the result showing that less than half of students reported daily school day intake of many healthy dietary choices. The result that less than 30% of students reported the purchase of convenience food items and beverages in the present study indicates that the majority of students do not frequently purchase from convenience food establishments during school or on their way to or from school. This finding may have resulted from limited opportunities for purchasing among elementary school students on schools days, as was discussed with respect to results of intake of Bottled water and Snack foods. However, there are also many additional factors that may have influenced the results of the food practice of convenience food establishment purchasing. For example, there is a possibility that many convenience food establishments are not in close proximity to certain schools or that the establishments that are available to students may not provide items that reflect student dietary preferences, thus limiting purchases among students. In comparison to the finding revealing that < 20 % of students reported weekly school day purchasing at the thre
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Participation in school food and nutrition programs and associations with dietary psychosocial and behavioural… Stephens, Teya Anne-Margaret 2014
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| Title | Participation in school food and nutrition programs and associations with dietary psychosocial and behavioural outcomes among Vancouver students in grades 6-8 |
| Creator |
Stephens, Teya Anne-Margaret |
| Publisher | University of British Columbia |
| Date Issued | 2014 |
| Description | Background: Diet-related health conditions, including obesity and type 2 diabetes, are a growing concern among Canadian youth. In Canada, there is also a rising interest in the impact of dietary choices on environmental sustainability. Several school food and nutrition programs (SFNPs) have been implemented to improve dietary quality and environmental sustainability, including gardening and food preparation programs. However, limited research has examined the links between participation in SFNPs and dietary psychosocial and behavioural outcomes. Purpose: To examine healthy and environmentally sustainable dietary attitudes, expectations, choices, and practices, and current participation rates in SFNPs among Vancouver students in grades 6-8, and to evaluate whether participation in SFNPs is associated with these outcomes. Methods: A cross-sectional study was conducted in 26 schools in Vancouver from March-June, 2012 (n=937 students). Schools were selected using non-probability sampling. A web-based survey, including a food frequency questionnaire, measured student demographic characteristics, participation in SFNPs, and dietary psychosocial and behavioural outcomes. Rao-Scott corrected chi-square tests were applied to assess associations between SFNPs and outcomes (p<0.05). Results: Less than 50% of students reported participating in SFNP activities, with the exception of recycling (51.2%). Greater than 50% reported the importance of health and environmental sustainability when making food purchases, and agreement that food choices impact health or the environment. However, < 50% of students reported daily intake of most healthy and weekly intake of most environmentally sustainable dietary choices. Approximately 1/3 of students reported weekly purchasing from convenience food establishments. Participation in activities specific to learning about food or nutrition was greater among females, and secondary school students reported greater participation in food-specific activities. Activities specific to learning about food or nutrition demonstrated expected associations with outcomes. Most associations between hands-on food-related activities were in the unanticipated direction. Conclusions: Findings demonstrate marginal participation in SFNPs and intake of healthy and environmentally sustainable dietary choices among Vancouver students. Results also reveal the possible role of activities specific to learning about food or nutrition in promoting healthy and environmentally sustainable diet-related outcomes. Further research on SFNPs to inform curriculum changes could improve student dietary behavioural outcomes, student health, and environmental sustainability. |
| Genre |
Thesis/Dissertation |
| Type |
Text |
| Language | eng |
| Date Available | 2014-07-02 |
| Provider | Vancouver : University of British Columbia Library |
| Rights | Attribution-NonCommercial-NoDerivs 2.5 Canada |
| DOI | 10.14288/1.0167243 |
| URI | http://hdl.handle.net/2429/47090 |
| Degree |
Master of Science - MSc |
| Program |
Human Nutrition |
| Affiliation |
Land and Food Systems, Faculty of |
| Degree Grantor | University of British Columbia |
| GraduationDate | 2014-09 |
| Campus |
UBCV |
| Scholarly Level | Graduate |
| Rights URI | http://creativecommons.org/licenses/by-nc-nd/2.5/ca/ |
| AggregatedSourceRepository | DSpace |
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