Trimming the Fat: School-based Child Obesity Prevention in British Columbia by Thomas Williams B.A. (Hons., Psychology), University of Winnipeg, 2003 Capstone Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Policy in the School of Public Policy Faculty of Arts and Social Sciences © Thomas Williams 2014 SIMON FRASER UNIVERSITY Spring 2014 Approval Name: Thomas Williams Degree: Master of Public Policy Title of Thesis: Trimming the Fat: School-based Child Obesity Prevention in British Columbia Examining Committee: Chair: Nancy Olewiler Director, School of Public Policy, SFU Dominique M. Gross Senior Supervisor Professor Doug McArthur Supervisor Professor Judith Sixsmith Internal Examiner Professor Date Defended: April 7, 2014 ii Partial Copyright Licence iii Ethics Statement iv Abstract This study investigates ways to improve the health and well-being of children in British Columbia (BC) through the education system. Despite BC's efforts, many BC children do not consume a healthy diet at school. A broad examination of case studies is used to ascertain common criteria for a health promoting school, while a detailed analysis of these criteria confirm that they are indeed indispensable for BC. Drawing on these findings, I formulate three policy options and conduct a policy analysis. The policy options are evaluated based on their ability to meet four criteria: effectiveness, cost, implementation complexity, and key stakeholder acceptability. Results indicate that legislating and enforcing the Guidelines for Food and Beverage Sales in BC Schools is the best option for BC in improving the health and well-being of schoolchildren. I recommend the legislation and enforcement of the Guidelines to the BC Ministry of Education because of the policy options ability to improve the school food environment, reduce child obesity prevalence, relative low costs, and ease of implementation. Keywords: child obesity; school nutrition; prevention; policy; British Columbia; recommendations v Acknowledgements I would like to dedicate this work to my capstone supervisor, family, coworkers, and friends who showed me continuous support during this challenging year. Dominique Gross was the ideal supervisor. Her sage advice provided me with necessary direction. Her composure and confidence gave me peace of mind. Her patience and availability allowed for me to excel. You have aided me in writing this thesis in innumerable ways. I would also like to thank Judith Sixsmith whose insightful questions and feedback during my defence helped strengthen my thesis. To my Mom, your positive outlook in life is a true inspiration. I would not have been able to complete this year without your steadfast display of unconditional love. To my friends at JJ, coming into work and seeing everyone’s smiles and greetings always made me feel a little bit better about life. This was an often much needed digression from the monotony of writing one report after another. You are all creative, smart, and a true inspiration to me. To my friends and colleagues in the MPP program, what an adventure. Each and every one of you taught me a little something about policy, life, and about myself over the past two years. As we move forward, I wish you all the best. I can imagine that like myself, you came into this program with a certain goal in mind. Let’s not lose focus of that goal. We are one step closer in achieving it. Lastly, I would like to thank my good friend Jonathon A. for always being there when I needed a friend to talk to. It’s nice knowing that I not only came away from this program with a Masters degree, but also a lifelong friend. You are an amazingly gifted individual. vi Table of Contents Approval ............................................................................................................................. ii Partial Copyright Licence .................................................................................................. iii Ethics Statement ............................................................................................................... iv Abstract .............................................................................................................................. v Acknowledgements ........................................................................................................... vi Table of Contents ............................................................................................................. vii List of Tables ...................................................................................................................... x List of Figures .................................................................................................................... x Executive Summary .......................................................................................................... xi Chapter 1. Introduction ................................................................................................ 1 Chapter 2. Obesity Definition and Risk Factors ......................................................... 4 2.1. Health at Every Size ................................................................................................ 4 2.2. Direct Risk Factors ................................................................................................... 5 2.3. Indirect Risk Factors ................................................................................................ 7 Chapter 3. Impact on Children ................................................................................... 11 Chapter 4. Obesity and Academic Performance ...................................................... 14 4.1. Relationship ........................................................................................................... 14 4.2. Role of Schools ...................................................................................................... 15 Chapter 5. British Columbia ....................................................................................... 16 5.1. Obesity in British Columbia .................................................................................... 16 5.2. School Food Availability ......................................................................................... 16 5.3. British Columbia Institutions ................................................................................... 17 Summary .......................................................................................................... 22 Chapter 6. Policy Problem and Stakeholders .......................................................... 25 Chapter 7. Methodology ............................................................................................. 27 7.1. Evaluation Framework ........................................................................................... 29 Chapter 8. Case Studies ............................................................................................. 34 Sources ............................................................................................................ 34 vii 8.1. Annapolis Valley Health Promoting Schools (Nova Scotia, Canada) .................... 35 8.1.1. Teaching and Learning ............................................................................... 35 8.1.2. Nutritional Services .................................................................................... 36 8.1.3. Partnerships and Services ......................................................................... 37 8.1.4. Implementation ........................................................................................... 38 8.2. Singapore ............................................................................................................... 38 8.2.1. Teaching and Learning ............................................................................... 38 8.2.2. Nutritional Services .................................................................................... 39 8.2.3. Partnerships and Services ......................................................................... 40 8.2.4. Implementation ........................................................................................... 40 8.3. England .................................................................................................................. 41 8.3.1. Teaching and Learning ............................................................................... 41 8.3.2. Nutritional Services .................................................................................... 42 8.3.3. Partnerships and Services ......................................................................... 42 8.3.4. Implementation ........................................................................................... 43 8.4. Case Study Analysis Summary .............................................................................. 43 8.5. BC and Common CSH Features ............................................................................ 46 8.6. Secondary Methodology ........................................................................................ 49 8.6.1. Training for Food Service Staff ................................................................... 49 8.6.2. Nutritional Standards .................................................................................. 50 8.6.3. Access to Healthy Foods ...........................................................................