Rebecca Ganann, Assistant Clinical Professor, School of Nursing, McMaster University, presents findings from her recently published review: Ganann R., Fitzpatrick-Lewis D., Ciliska D., Peirson L.J., Warren R.L., Fieldhouse P., et al. (2014). Enhancing nutritional environments through access to fruit and vegetables in schools and homes among children and youth: A systematic review. BMC Research Notes,7(422), 1-13. Low fruit and vegetable consumption is one of the top 10 global risk factors for mortality, and is related to increased risk for cancer, cardiovascular disease and diabetes. Many environmental, sociodemographic and personal factors affect fruit and vegetable consumption. This review explores strategies to improve fruit and vegetable availability. For a recording of this webinar, visit: https://youtu.be/PrEPKWtFTpY

1. Welcome!
Enhancing nutritional
environments through access to
fruit & vegetables in schools and
homes among children & youth:
What's the Evidence?
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2. What’s the evidence?
• Ganann, R., Fitzpatrick-Lewis, D., Ciliska, D.,
Peirson, L., Warren, R., Fieldhouse, P., et al.
(2014). Enhancing nutritional environments
through access to fruit and vegetables in schools
and homes among children and youth: a
systematic review. BMC Research Notes, 7:422.
DOI: 10.1186/1756-0500-7-422
• http://www.healthevidence.org/view- article.aspx?a=28

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4. Welcome!
Enhancing nutritional
environments through access to
fruit & vegetables in schools and
homes among children & youth:
What's the Evidence?

5. The Health Evidence Team
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7. Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
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8. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

9. Stages in the process of Evidence-
Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informed
Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

10. Review
•Ganann, R., Fitzpatrick-Lewis, D., Ciliska, D.,
Peirson, L., Warren, R., Fieldhouse, P., et al.
(2014). Enhancing nutritional environments
through access to fruit and vegetables in schools
and homes among children and youth: a
systematic review. BMC Research Notes, 7:422.
DOI: 10.1186/1756-0500-7-422

11. Importance of this Review
• Low fruit and vegetable (FV) consumption is a
risk factor for morbidity and mortality
• Adequate FV consumption can play a protective
role in chronic disease and cancer
• Increasing consumption of FV:
• Need to focus upstream and beyond individual level
education and behaviour modification
• Interventions to improve availability and
accessibility of FV (upstream of the individual)
may increase consumption

12. Systematic review lead author
Rebecca Ganann is a registered nurse, PhD student,
and Assistant Clinical Professor in the School of
Nursing at McMaster. She was the recipient of a
CIHR Vanier Canada Graduate Scholarship and is
currently a Strategic Training Fellow in Interdisciplinary
Primary Health Care Research.
Rebecca’s research interests include primary health care, addressing
health inequities, service accessibility, chronic disease prevention and
management, knowledge translation, and evidence-informed decision-
making.

13. Poll Question #1
Who has heard of PICO(S) before?
1.Yes
2.No

14. Searchable Questions Think “PICOS”
1. Population (situation)
2. Intervention (exposure)
3. Comparison (other group)
4. Outcomes
5. Setting

15. Review Focus:
• P Any person or institution that can change FV
environment for school aged children (5-18 yr. olds)
• I Aimed at modifying population level FV
environment
• C Different interventions or no intervention
• O Change in food environment to increase FV
accessibility
• S Community-based settings

16. Where did we search for evidence?
• 19 databases
– Peer-reviewed literature
– Grey literature
• Targeted internet search
• Hand search
– target journals & conference proceedings
– reference lists
• Advised by experts, authors, researchers,
and relevant policy-makers

17. How did we select studies to include?
1. Title and abstract
2. Full text review
• Two independent reviewers with third
reviewer to resolve disagreements
regarding inclusion

18. Articles were included if:
• In English, French and Spanish
• From high-, middle-, and low-income countries
• Delivered to anyone who could bring about
change in FV environment for 5 to 18 year olds
• Randomized and non-randomized study designs
that provided before-after comparisons, with or
without a control group
• Primary outcomes of interest were measures of
FV availability

20. Data extraction - Characteristics
• Study design
• Participants, setting(s), & intervention(s)
• Outcomes
– Primary: FV supply, change in food
environment, FV transition
– Secondary: consumption of FV, awareness,
attitudes, general health measures, adverse/
unintended outcomes

21. Risk of Bias (RoB)
• Cochrane Collaboration’s tool for RoB
– Sequence generation
– Allocation concealment
– Blinding of participants and personnel
– Blinding of outcome assessment
– Incomplete outcome data
– Outcome reporting
– Other: validated & reliable tools, intention-to-treat,
intervention integrity, statistical approaches
• Ratings: low, unclear, high RoB

22. Study characteristics
• ~23,000 citations resulted in 23 unique
studies included (1.2% of retrieved)
– Research from USA, South Africa,
Netherlands, UK, France
– Quasi-experimental, cluster-controlled,
before-after (no control group)
– Conducted in schools, some home-based
components, Boy Scout troop, Internet
settings

23. Risk of bias assessment
• Quality of study is inversely related to risk
of bias
– High quality = low risk of bias
– Low quality = high risk of bias
• All 23 included studies were rated as
having high risk of bias
– Less confidence in findings

24. What did we find?
• Two intervention types
– Policies
– Programs
• Target audience(s)
– Children
– Children and parents
– General population
– School teachers

25. Target of interventions
• Policies:
– School food service
– Price of FV
– School and broader food environments
• Programs:
– School food service
– Home and families
– Communities or community programs

26. What did we learn?
• Interventions targeting local school food
policies were most promising for improving
food environment
• More conservative or mixed impact:
– State of federally mandated policies or
educational programs for food service
providers and decision makers
– Family interventions

27. Hartstein et al., 2011
Methods Randomized controlled trial
Participants 30 middle schools
Interventions Dieticians worked with school to change in-school
vending machine offerings
Comparison No dietician
Outcomes Number of vending machine slots allocated to fruit
juice, sugar-added beverages, and dessert offering
Number of vending machine slots:
•Intervention schools decreased from 31% to 0%.
•Control schools increased from 13% to 43%.

28. Haroun et al., 2011
Methods Before-after study
Participants 139 primary schools at baseline
136 schools at follow-up
Interventions New food-based standards (FBS) for catering
provision of lunchtime in-school services
Outcomes FV provision before and after change in FBS
(2005 vs. 2009)
School under new FBS providing significantly
more vegetables and salad (4.0%), fruit (3.0%)
and fruit juice (1.2%)

29. Cassady et al., 2006
Methods Before-after
Participants 44 public elementary schools; ~ 8,000 children in
after-school program
Interventions New school-based policy to increase servings of
FV offered within an after-school program to be
consistent with “5 a day” guidelines from new
organizational policy
Outcomes Changes in average daily FV servings from old
menu to new menu
Fruit servings: Increased from 0.6 to 1.1
Vegetable servings: No change (0.0 to 0.0)
Unintended result: Milk provision decreased after
intervention

30. Goldberg et al., 2009
Methods Before-after
Participants Elementary school food service staff, students, parents,
teachers, and school leaders
Interventions School food service intervention consisting of school
meal menu changes, professional development and
capacity building and communication strategies.
Outcomes FV availability in school meals before and after
intervention
Menu changes (frequency per week):
•Fresh fruits and breakfast: Increased from 2 to 5
•Fresh fruits at lunch: Increased from 2 to 5
•Entree salads at lunch: Increased from 2 to 3
•Side salads at lunch: Increased from <1 to 1

31. Cullen et al., 2009
Methods Before-after
Participants 47 schools:
•19 primary schools; 28 secondary schools
•23 schools in small districts; 24 schools in large districts
Interventions School Nutrition Policy that restricts the portion sizes of
high-fat and sugar snacks, limits the fat content of milk,
provides guidelines for the fat content of foods served,
and sets limits on the frequency of serving high-fat
vegetables such as french fries
Outcomes Change in FV servings before and after intervention
No significant improvement in fruit servings between
school years (pre and post implementation)

32. Cullen et al., 2006
Methods Before-after
Participants 3 middle schools (2,970 students)
Interventions Food Service Director implemented local school food
policy changes including removal of snack chips, candy,
sweet desserts and sweetened beverages from snack
bars and removal of vending machines from the cafeterias
Outcomes Changes in FV sales and intake of FV.
No change in FV sales
No change in daily intake of fruit and juice
Small reduction in daily servings of vegetables (0.3 to 0.2)

33. Considerations
• Difficult to classify interventions because
of multiple components
– Policy vs. program
– School vs. municipal vs. state-wide vs. federal
– Target of intervention
• Different outcome measures
– Change in FV environment
– Changes in FV supply
– Food sales

34. What do we need?
• Controlled study designs
• Studies focused on low- and middle-
income contexts
• Standardized measurement tools of food
environment, access, and consumption
– Reliable and validated
• For population-based interventions,
should report subgroup analyses (e.g., by
age)

35. Summary of author findings
• There are promising strategies to improve
the FV environment for children,
particularly through local school food
service policies
• Broader state or federally mandated
programs had mixed or small impact
• Family interventions had no or small
impact on home accessibility

36. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

37. Poll Question #2
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today helpful?
1.Yes
2.No

38. Poll Question #3
Was this information new to you?
1.Yes
2.No

39. Questions?

40. Thank you!
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