Foods and beverages available to children in settings outside of the home: Research, policy, and monitoring considerations/Les aliments et boissons auxquels les enfants ont acces hors de la maison : aspects a considerer lies a la recherche, aux politiques et a la surveillance.
Kirkpatrick, Sharon I.
The provision of healthy food and beverage choices within settings in which children learn and play is critical to their development of healthy eating patterns. In this issue of CJPH, Ward et al. (1) report on the healthfulness of foods offered within child care settings in two provinces. Specifically, the authors assessed the nutritional profile of lunches, with a focus on food groups from Canada's Food Guide and dietary components that are the focus of current policy attention, including sugars and sodium. (2) Lunch offerings were generally suboptimal, lacking in fruits, vegetables, meat and alternates, and fibre. The authors found that, according to the standards employed, levels of fats (total, saturated, and trans) and sugars were within recommended amounts, while those of sodium were not. While there have been efforts to reduce trans fats in the food supply, sugars and sodium content remains high, particularly in packaged and processed foods. The conflicting findings for sugars and sodium may reflect uptake among centre staff of sugar-related public health and media messaging, whereas for sodium, attention has arguably focused more strongly on reformulation. (2) Further exploration of child care centre practices in terms of reliance on packaged and processed foods could provide interesting insights into sources of sodium. In any case, despite possible attention to levels of fats and sugars in lunches served to young children outside of the home, the overall nutritional profile was low, underscoring the need to promote healthy dietary patterns holistically (3) as opposed to a narrow emphasis on specific aspects of foods and beverages.
Through their focus on child care settings, Ward et al.'s work contributes to a broader understanding of food environments in settings in which children spend significant amounts of time, with implications for daily intake as well as the development of longer-term food preferences and eating patterns. The authors point to the potential need for comprehensive guidelines for foods offered in child care centres, as well as nutrition education for staff. These interventions are consistent with frameworks such as NOURISHING (4) (developed by the World Cancer Research Fund) that identify a range of actions to promote healthy eating. The "O" in NOURISHING refers to offering healthy food and setting standards in public institutions and other specific settings. In Canada, there are standards in place to promote healthy food environments for children in particular settings; for example, Policy/Program Memorandum No. 150 (5) provides nutrition standards for Ontario schools, and applies to all venues, programs, and events on school properties. However, as Ward et al. note, there is much variation in guidelines for foods offered within child care centres. A similar observation has been made for school breakfast programs, (6) speaking to the need for a comprehensive and linked-up set of guidelines that helps to ensure that children are provided with environments that support healthy eating across settings and throughout the lifecycle. The "G" in NOURISHING relates to giving nutrition education and skills. As an example, initiatives to support food literacy (7) among both children and the adults with whom they interact may be needed to improve acceptance of guidelines and the resulting food and beverage offerings. Such interventions require evaluation both in terms of process and outcomes; indeed, a 2014 systematic review of the international literature on preschools found a scarcity of well-designed intervention research targeting healthy eating. (8)
Given evidence that children's current dietary patterns are divergent from recommendations (9) and the central role that environmental factors play in shaping food choices, (2-4) broader changes to the food environments to which Canadians are exposed are needed to reinforce efforts within specific settings. Such efforts may draw upon other facets of NOURISHING, such as economic tools (e.g., taxes) and strategies related to the nutritional quality of the food supply, (4) and may foster shifts in norms related to food and healthy eating among Canadians (in Ward et al.'s research, social norms were suggested to play a role in differences in nutritional profiles between French- and English-speaking centres). It is promising that the Canadian government has launched a Healthy Eating Strategy that aims to "make the healthy choice the easy choice". (2) In addition to revising Canada's Food Guide, pursuing front-of-pack nutrition labels for packaged foods, and initiatives to reduce sodium and trans fats in the food supply, Health Canada is consulting on measures to restrict marketing of unhealthy foods and beverages to children. Along with these initiatives, collaboration with provinces and territories to develop comprehensive standards to regulate the foods available in child care centres, schools, and other settings that cater to children appears warranted.
To evaluate the success of strategies such as guidelines and complementary initiatives, ongoing monitoring is critical. The development of an inventory of policies relevant to food environments at the provincial/territorial and federal levels in Canada, using the International Network for Food and Obesity/ non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) Healthy Food Environment Policy Index, (10) may address this need. The data gathered may be useful for monitoring the level of implementation of policies (such as standards for foods offered to children outside of the home) across jurisdictions, for understanding how such policies fit into the wider context of strategies to improve food environments (within the food sector but also related to trade and zoning, for example), and for identifying policy gaps.
In regards to monitoring impacts of strategies on children's diets, assessing what children eat and drink is not a simple task. It is worth noting the care that Ward et al. took in characterizing the foods served. Plate waste was also measured, lending to their ability to conduct future analyses to shed insights into what children actually consumed relative to what was offered. Similarly conducted research in other jurisdictions could provide comparative data to shed light on the extent to which guidelines or other approaches influence consumption, as well as food preferences and attitudes among children, with the goal of providing a foundation for lifelong healthy eating.
Sharon I. Kirkpatrick
Assistant Professor, School of Public Health and Health Systems, University of
Waterloo, Waterloo, ON
Correspondence: Sharon I. Kirkpatrick, E-mail: sharon.kirkpatrick@uwaterloo.ca
doi: 10.17269/CJPH.108.6371
REFERENCES
(1.) Ward S, Belanger M, Donovan D, Vatanparast H, Engler-Stringer R, Leis A, et al. Lunch is ready ... but not healthy: An analysis of lunches served in childcare centres in two Canadian provinces. Can J Public Health 2017; 108(4): e342-47.
(2.) Health Canada. Healthy Eating Strategy, 2016. Available at: https://www. canada.ca/en/health-canada/services/publications/food-nutrition/healthyeating- strategy.html (Accessed July 20, 2017).
(3.) U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans, 8th ed. 2015. Available at: http://health.gov/dietaryguidelines/2015/ (Accessed July 20, 2017).
(4.) Hawkes C, Jewell J, Allen K. A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: The NOURISHING framework. Obes Rev 2014; 14:159-68. PMID: 24103073. doi: 10.1111/obr.12098.
(5.) Ontario Ministry of Education. Policy/Program Memorandum No. 150, 2010. Available at: http://www.edu.gov.on.ca/extra/eng/ppm/150.html (Accessed July 20, 2017).
(6.) Godin KM, Kirkpatrick SI, Hanning RM, Stapleton J, Leatherdale ST. Examining guidelines for school-based breakfast programs in Canada: A systematic review of the grey literature. Can J Dietet Pract Res 2017; 78(2): 92-100. PMID: 28145767. doi: 10.3148/cjdpr-2016-037.
(7.) Perry EA, Thomas H, Samra HR, Edmonstone S, Davidson L, Faulkner A, et al. Identifying attributes of food literacy: A scoping review. Public Health Nutr 2017; 20(13):2406-15. PMID: 28653598. doi: 10.1017/S1368980017001276.
(8.) Mikkelson MV, Husby S, Skov LR, Perez-Cueto FJA. A systematic review of types of healthy eating interventions in preschools. Nutr J 2014; 13:56. PMID: 24906305. doi: 10.1186/1475-2891-13-56.
(9.) Garriguet D. Canadians' eating habits. Health Rep 2007; 18(2):17-32. PMID: 17578013.
(10.) Vanderlee L, Karbasy K, L'Abbe M. An analysis of action regarding food environment policies in Canada by jurisdiction. Canadian Nutrition Society: Scientific Abstracts from the 8th Annual Scientific Meeting, May 25-27, 2017, Montreal, QC, 2017. Available at: https://cns-scn.ca/sites/default/uploads/ files/apnm-2017-0134.pdf (Accessed July 20, 2017).
Pour que les enfants developpent de saines habitudes alimentaires, il est essentiel de leur presenter des choix d'aliments et de boissons sante dans leurs milieux d'apprentissage et de jeu. Dans ce numero de la RCSP, Ward et coll. (1) rendent compte de la valeur nutritive des aliments offerts en milieu de garde dans deux provinces. Plus precisement, les auteurs ont evalue le profil nutritionnel des dejeuners, en mettant l'accent sur les groupes d'aliments du Guide alimentaire canadien et les composants alimentaires cibles par les politiques actuelles, notamment les sucres et le sodium (2). Les dejeuners proposes etaient generalement sous-optimaux; ils manquaient de fruits, de legumes, de viande et substituts et de fibres. Les auteurs ont constate que selon les normes employees, les niveaux de gras (totaux, satures et trans) et de sucres etaient a l'interieur des limites recommandees, mais que ce n'etait pas le cas pour le sodium. Des efforts ont ete faits pour reduire les gras trans dans l'alimentation, mais les teneurs en sucres et en sodium restent elevees, surtout dans les aliments emballes et transformes. Les constatations opposees concernant les sucres et le sodium pourraient s'expliquer par le fait que le personnel des centres a entendu les messages des autorites de sante publique et des medias sur le sucre, tandis que pour le sodium, l'attention s'est peut-etre davantage portee sur la reformulation (2). Une exploration plus poussee des pratiques des centres de la petite enfance en ce qui a trait aux aliments emballes et transformes pourrait donner un apercu interessant des sources de sodium. Quoi qu'il en soit, meme si l'on fait attention aux niveaux de gras et de sucres dans les dejeuners servis aux jeunes enfants hors de la maison, leur profil nutritionnel global est faible, d'ou le besoin de promouvoir de saines habitudes alimentaires en general (3) plutot que de se concentrer strictement sur des aspects particuliers des aliments et boissons.
Du fait qu'ils portent sur les milieux de garde, les travaux de Ward et coll. contribuent a elargir les connaissances des environnements alimentaires dans les milieux ou les enfants passent beaucoup de temps, ce qui a des consequences sur leurs apports quotidiens et, a long terme, sur leur acquisition de preferences alimentaires et leurs habitudes alimentaires. Les auteurs indiquent que des directives completes sur les aliments offerts dans les centres de la petite enfance pourraient
etre necessaires, ainsi qu'une education alimentaire du personnel des centres. Ces interventions sont conformes aux cadres comme NOURISHING (4) (elabore par le World Cancer Research Fund), qui definit un eventail de mesures pour promouvoir l'alimentation saine. La lettre O dans NOURISHING designe l'offre (offering) d'aliments sains et l'instauration de normes dans les etablissements publics et autres milieux particuliers. Au Canada, des normes ont ete mises en place pour promouvoir les environnements alimentaires sains pour les enfants dans certains milieux; par exemple, la Note no. 150 des politiques et des programmes (5) presente les normes de nutrition des ecoles de l'Ontario et s'applique dans l'enceinte de l'ecole, quel que soit l'endroit, le programme et l'occasion. Comme le notent Ward et coll. cependant, les directives sur les aliments offerts dans les centres de la petite enfance varient beaucoup. Il en va de meme pour les programmes de petits dejeuners dans les ecoles (6), ce qui confirme le besoin d'un jeu de directives completes et liees pour que l'environnement des enfants favorise l'alimentation saine dans tous les milieux et pendant tout le cycle de vie. La lettre G dans NOURISHING designe la prestation (giving) d'une education alimentaire et de competences en matiere de nutrition. A titre d'exemple, des initiatives favorisant la litteratie alimentaire (7) chez les enfants et les adultes avec qui ils interagissent pourraient etre necessaires pour ameliorer l'acceptation des directives, et donc les aliments et boissons proposes. Tant le processus que les effets de telles interventions doivent etre evalues; en fait, en 2014, une revue systematique de la litterature scientifique internationale sur les etablissements prescolaires a constate la rarete des etudes de recherche d'intervention bien concues portant sur la saine alimentation (8).
Vu les preuves que les habitudes alimentaires actuelles des enfants s'ecartent des recommandations (9) et le role central joue par les environnements alimentaires dans la formation des choix alimentaires (2-4), il faut apporter des changements plus vastes aux environnements alimentaires auxquels les Canadiens sont exposes pour renforcer les efforts dans des milieux particuliers. Ces efforts peuvent s'inspirer des autres facettes du cadre NOURISHING, comme les outils economiques (p. ex. les taxes), et des efforts pour ameliorer la qualite nutritionnelle des disponibilites alimentaires (4); ils peuvent aussi favoriser des changements dans les normes d'aliments et de saine alimentation des Canadiens (selon l'etude de Ward et coll., les normes du groupe jouent un role dans les differences entre le profil nutritionnel des centres francophones et anglophones). Il est prometteur que le gouvernement canadien ait lance une Strategie pour une saine alimentation qui vise a faire << que les choix alimentaires les plus sains soient les plus faciles a faire (2) >>. En plus de reviser le Guide alimentaire canadien, d'explorer la possibilite d'apposer les etiquettes nutritionnelles sur le devant des aliments emballes et de piloter des initiatives pour reduire le sodium et les gras trans dans l'alimentation, Sante Canada mene des consultations sur des mesures de restriction a la publicite de boissons et d'aliments malsains destinee aux enfants. De concert avec ces initiatives, une collaboration avec les provinces et les territoires pour elaborer des normes completes regissant les aliments disponibles dans les centres de la petite enfance, les ecoles et les autres milieux qui accueillent des enfants semble justifiee.
Pour evaluer l'efficacite des strategies comme les directives et les initiatives complementaires, il est essentiel d'exercer une surveillance constante. La constitution d'un repertoire de politiques applicables aux environnements alimentaires a l'echelle provinciale-territoriale et federale au Canada, a l'aide de l'indice Healthy Food Environment Policy Index (10) du reseau INFORMAS (International Network for Food and Obesity/noncommunicable Diseases Research, Monitoring and Action Support), pourrait repondre a ce besoin. Les donnees recueillies pourraient etre utiles pour surveiller les niveaux d'application des politiques (comme les normes d'aliments offerts aux enfants hors de la maison) d'une province ou d'un territoire a l'autre, afin de comprendre comment ces politiques s'inscrivent dans le contexte des strategies d'amelioration des environnements alimentaires (dans le secteur des aliments, mais aussi en lien avec le commerce et le zonage, par exemple) et pour deceler les lacunes dans les politiques.
En ce qui concerne la surveillance des impacts des strategies sur le regime des enfants, il n'est pas simple d'evaluer ce que les enfants mangent et boivent. Il est interessant de noter le soin avec lequel Ward et coll. ont caracterise les aliments servis. Ils ont meme mesure les restes dans les assiettes, ce qui leur permettra un jour de proceder a des analyses de ce que les enfants consomment vraiment par rapport a ce qui leur est servi. Des recherches menees de la meme facon dans d'autres provinces ou territoires pourraient fournir des donnees comparatives pour determiner la mesure dans laquelle les directives ou d'autres strategies influencent la consommation des enfants, leurs preferences alimentaires et leurs attitudes face aux aliments, dans le but de leur offrir les fondements d'une saine alimentation pour le reste de leur vie.
Sharon I. Kirkpatrick
Professeure adjointe, Ecole de sante publique et des systemes de sante,
Universite de Waterloo, Waterloo (Ontario)
Correspondance : Sharon I. Kirkpatrick, Courriel : sharon.kirkpatrick@uwaterloo.ca
doi: 10.17269/CJPH.108.6371
REFERENCES BIBLIOGRAPHIQUES
(1.) Ward S, Belanger M, Donovan D, Vatanparast H, Engler-Stringer R, Leis A, et al. Lunch is ready ... but not healthy: An analysis of lunches served in childcare centres in two Canadian provinces. Can J Public Health 2017; 108(4): e342-47.
(2.) Health Canada. Healthy Eating Strategy, 2016. Sur Internet : https://www. canada.ca/en/health-canada/services/publications/food-nutrition/healthyeating- strategy.html (consulte le 20 juillet 2017).
(3.) U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans, 8th ed. 2015. Sur Internet: http://health.gov/dietaryguidelines/2015/ (consulte le 20 juillet 2017).
(4.) Hawkes C, Jewell J, Allen K. A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: The NOURISHING framework. Obes Rev 2014; 14:159-68. PMID: 24103073. doi: 10.1111/obr.12098.
(5.) Ontario Ministry of Education. Policy/Program Memorandum No. 150, 2010. Sur Internet : http://www.edu.gov.on.ca/extra/eng/ppm/150.html (consulte le 20 juillet 2017).
(6.) Godin KM, Kirkpatrick SI, Hanning RM, Stapleton J, Leatherdale ST. Examining guidelines for school-based breakfast programs in Canada: A systematic review of the grey literature. Can J Dietet Pract Res 2017; 78(2): 92-100. PMID: 28145767. doi: 10.3148/cjdpr-2016-037.
(7.) Perry EA, Thomas H, Samra HR, Edmonstone S, Davidson L, Faulkner A, et al. Identifying attributes of food literacy: A scoping review. Public Health Nutr 2017; 20(13):2406-15. PMID: 28653598. doi: 10.1017/S1368980017001276.
(8.) Mikkelson MV, Husby S, Skov LR, Perez-Cueto FJA. A systematic review of types of healthy eating interventions in preschools. Nutr J 2014; 13:56. PMID: 24906305. doi: 10.1186/1475-2891-13-56.
(9.) Garriguet D. Canadians' eating habits. Health Rep 2007; 18(2):17-32. PMID: 17578013.
(10.) Vanderlee L, Karbasy K, L'Abbe M. An analysis of action regarding food environment policies in Canada by jurisdiction. Canadian Nutrition Society: Scientific Abstracts from the 8th Annual Scientific Meeting, May 25-27, 2017, Montreal, QC, 2017. Sur Internet : https://cns-scn.ca/sites/default/uploads/ files/apnm-2017-0134.pdf (consulte le 20 juillet 2017).
