Examining the Role of the School Food Environment in Moderating Sugar-sweetened Beverage Consumption Among Adolescents in Alberta and Ontario, Canada: Cross-sectional and Longitudinal Evidence from the COMPASS Study

Adolescents represent the greatest consumers of sugar-sweetened beverages (SSBs) in Canada, which is concerning, given the numerous adverse health outcomes associated with frequent SSB intake. Provincial school nutrition policies represent one population-level strategy intended to promote healthy dietary choices among Canadian youth. Both the Alberta Nutrition Guidelines for Children and Youth (ANGCY) and Ontario’s Policy/program Memorandum no. 150 (P/PM 150) recommend restrictions in SSB availability in school food outlets (e.g., cafeterias, vending machines, etc.) to decrease students’ access to products. There exists a broad range of contextual factors outside of schools that influence youths’ dietary choices; influences within other environments (e.g., the home, community, and larger regulatory contexts) can support or undermine school-based interventions, and should be accounted for in the development and evaluation of these initiatives. This dissertation research used the socioecological model as a theoretical framework to examine the role of the school context in influencing Canadian adolescents’ SSB intake in Alberta and Ontario. The objectives were to (i) characterize Canadian adolescents’ SSB consumption patterns; (ii) describe school food environment characteristics in Canadian secondary schools; (iii) describe how these characteristics reflect school-level compliance with provincial school nutrition policies; (iv) identify associations between school food environment characteristics and measures of students’ SSB intake; and, (v) identify potentially promising contexts and/or strategies for future population-level initiatives to reduce adolescents’ SSB intake. Three manuscripts served these objectives using student- and school-level data from the COMPASS study. The first two manuscripts represent cross-sectional analyses (2013/14), while the third manuscript includes longitudinal analyses (2013/14 to 2015/16). The first manuscript examined how several food purchasing behaviors (i.e., sources of meals/snacks) within and outside of the school context are associated with adolescents’ SSB consumption, and whether these associations vary by province. This study identified that most of the food purchasing behaviours were significantly and positively associated with greater rates of SSB consumption. Meal/snack purchases on weekends (versus weekdays) and from food outlets off-school property (versus on-school property) had a greater association with SSB consumption. The research identified a significantly higher rate of SSB intake among Albertan participants and a number of interesting interaction effects between province and various food purchasing behaviours, providing evidence that students’ rate of SSB intake may be related to differences in provincial school nutrition policies. The second manuscript provided a scoping assessment of several characteristics of the secondary school food environment (i.e., comprising features of the school and school neighbourhood) in Alberta and Ontario, provincial differences across these school characteristics, as well as whether these characteristics are associated with students’ SSB consumption rate. This study identified that participants had access to several potential sources of SSBs during their time in school; most schools were within walking distance of one or more external food outlets and a considerable proportion of schools stocked various types of SSBs in their vending machines. SSBs were significantly less available in Ontario schools’ vending machines compared to those in Alberta, suggesting that P/PM 150 is more effective than the ANGCY at restricting SSB availability in school vending machines. Few of the school food environment characteristics assessed were significantly associated with students’ SSB intake. The third manuscript examined changes in product availability within secondary schools’ beverage vending machines, changes in students’ weekday intake of SSBs over time, and the associations between these measures of beverage availability and SSB intake. Schools were separated into three policy groups: ‘Alberta’; ‘Ontario public schools’; and, ‘Ontario private schools’. Most SSB types examined were least available in Ontario public schools’ vending machines across all time points. Generally, vending machine beverage availability did not vary significantly over time. Across all policy groups, participants’ rate of soft drinks consumption decreased as they progressed through secondary school, while their intake of sweetened coffees/teas increased; other SSB outcome measures remained fairly stable. Students in Alberta reported the greatest frequency of SSBs intake across all time points and measures. There was limited evidence that changes in vending machine beverage availability was significantly associated with students’ SSB consumption. This dissertation enhances our current understanding of Canadian adolescents’ SSB intake patterns, the Canadian secondary school food environment, and the successes and shortcomings of school nutrition policies. This work signals the need for continued efforts to reduce adolescents’ SSB intake. This dissertation illustrates that the school food environment represents a source of SSBs for Canadian adolescents, since most schools are nearby external food outlets and many schools have SSBs available for sale within school vending machines. However, this research highlights that schools are one of many contexts that influences adolescents’ dietary behaviours, and efforts to limit the in-school availability of SSBs in vending machines have a limited impact on measures of adolescents’ SSB intake. This research signals the need for school-based interventions to be supported by parallel population-level initiatives that encourage healthy dietary choices among Canadians

Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada

Grey literature is an important source of information for large-scale review syntheses. However, there are many characteristics of grey literature that make it difficult to search systematically. Further, there is no ‘gold standard’ for rigorous systematic grey literature search methods and few resources on how to conduct this type of search. This paper describes systematic review search methods that were developed and applied to complete a case study systematic review of grey literature that examined guidelines for school-based breakfast programs in Canada. Methods: A grey literature search plan was developed to incorporate four different searching strategies: (1) grey literature databases, (2) customized Google search engines, (3) targeted websites, and (4) consultation with contact experts. These complementary strategies were used to minimize the risk of omitting relevant sources. Since abstracts are often unavailable in grey literature documents, items’ abstracts, executive summaries, or table of contents (whichever was available) were screened. Screening of publications’ full-text followed. Data were extracted on the organization, year published, who they were developed by, intended audience, goal/objectives of document, sources of evidence/resources cited, meals mentioned in the guidelines, and recommendations for program delivery. Results: The search strategies for identifying and screening publications for inclusion in the case study review was found to be manageable, comprehensive, and intuitive when applied in practice. The four search strategies of the grey literature search plan yielded 302 potentially relevant items for screening. Following the screening process, 15 publications that met all eligibility criteria remained and were included in the case study systematic review. The high-level findings of the case study systematic review are briefly described. Conclusions: This article demonstrated a feasible and seemingly robust method for applying systematic search strategies to identify web-based resources in the grey literature. The search strategy we developed and tested is amenable to adaptation to identify other types of grey literature from other disciplines and answering a wide range of research questions. This method should be further adapted and tested in future research syntheses

Systematic Search and Reporting Techniques Applied to the Gray Literature: A Review of Canadian School Breakfast Program Guidelines

This poster was presented at the Mosaic ’16 (Medical Library Association) Conference on May 17, 2016, Toronto, Ontario. Abstract: Methods: A grey literature search plan was developed to incorporate four different searching strategies: i) grey literature databases, ii) customized Google search engines, iii) targeted websites; and, iv) consultation with contact experts. These complementary strategies were used to minimize the risk of omitting relevant sources. Since abstracts are often unavailable in grey literature documents, items’ abstracts, executive summaries, or table of contents (whichever was available) were screened. Screening of publications’ full-text followed. Data were extracted on the organization, year published, who they were developed by, intended audience, goal/objectives of document, sources of evidence/resources cited, meals mentioned in the guidelines, and recommendations for program delivery. Results: The search strategies for identifying and screening publications for inclusion in the case study review was found to be manageable, comprehensive, and intuitive when applied in practice. The four search strategies of the grey literature search plan yielded 302 potentially relevant items for screening. Following the screening process, 15 publications that met all eligibility criteria remained and were included in the case study systematic review. Conclusions: This presentation demonstrates a feasible and seemingly robust method for applying systematic search strategies to identify web-based resources in the grey literature. The search strategy we developed and tested is amenable to adaptation to identify other types of grey literature from other disciplines and answering a wide range of research questions. This method should be further adapted and tested in future research syntheses