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Guideline Summary
Guideline Title
Healthy eating, physical activity, and healthy weights guideline for public health in Ontario.
Bibliographic Source(s)
Garcia J, Beyers J, Uetrecht C, Kennedy E, Mangles J, Rodrigues L, Truscott R, Expert Steering Committee of the Project in Evidence-based Primary Prevention. Healthy eating, physical activity, and healthy weights guideline for public health in Ontario. Toronto (ON): Cancer Care Ontario (CCO); 2010 Mar 17. 52 p. (PEBC report; no. 23-1).  [37 references]
Guideline Status

This is the current release of the guideline.

The PEBC report over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site External Web Site Policy for details on any new evidence that has emerged and implications to the guidelines.

Scope

Disease/Condition(s)

Obesity and the chronic diseases associated with obesity including, but not limited to:

  • Cancer (esophageal, pancreatic, colorectal, postmenopausal breast, endometrial, and kidney)
  • Diabetes
  • Heart disease
  • Stroke
Guideline Category
Counseling
Prevention
Clinical Specialty
Family Practice
Internal Medicine
Nursing
Nutrition
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
  • To provide specific, actionable recommendations that will enable public health and other professionals working in chronic disease prevention to make decisions about the provision and support of programs and resources for the promotion of healthy eating and physical activity
  • To evaluate what population-based strategies should be used by public health professionals, and other professionals working in chronic disease prevention, to prevent obesity among adults and children in Ontario schools, workplaces, and communities
Target Population

Ontario adults and children

Interventions and Practices Considered

Public health programs and interventions to encourage healthy eating and physical activity in the following targeted areas:

  • Elementary and secondary schools
  • Post-secondary schools
  • Workplaces
  • Food premises, such as supermarkets and restaurants
  • Municipalities
  • Community partnerships (community agencies, programs, and services)
  • Priority populations such as pregnant women, people involved in smoking cessation programs, and those of various socioeconomic status
  • Public awareness
  • Women who are breastfeeding and children in childcare facilities
Major Outcomes Considered

Promotion of good health in Ontario schools, communities, and workplaces

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Environmental Scan

An environmental scan was conducted to identify existing guidelines on obesity prevention. Searching for guidelines first, rather than for other types of evidence such as systematic reviews or randomized controlled trials (RCTs), is in keeping with established criteria for a hierarchy of public health evidence used when investigating public health questions (Figure 1 in the original guideline document shows one of several similar graphic representations of levels of evidence).

The environmental scan for existing guidelines included a search of international guideline developers identified by the Program in Evidence-based Care (PEBC) as preferred sources because of their credibility and rigour of guideline development. These included the Scottish Intercollegiate Guidelines Network (SIGN), the American Society of Clinical Oncology (ASCO), and the National Institute for Health and Clinical Excellence (NICE). Additional searches included the National Guideline Clearinghouse database and a Google (©2009) search. Expert Steering Committee members recommended that systematic reviews from the Effective Public Health Practice Project (EPHPP) should also be considered because of their applicability to the Ontario context. The EPHPP is an initiative of the Public Health Research, Education and Development Program (PHRED), which is jointly funded by the Ministry of Health and Long-term Care (MOHLTC) and the City of Hamilton Public Health Services. The Expert Steering Committee recognizes that, by using this strategy, in contrast to a full systematic review, other possibly relevant, high-quality guidelines and evidence sources might have been overlooked. However, in the interests of efficiency and avoiding duplication, and capitalizing on the high-quality sources that were included, the Committee stands by its decision.

Number of Source Documents

This guideline is adapted from one guideline.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Quality of the Public Health Evidentiary Base

The original recommendations generated by the National Institute for Health and Clinical Excellence (NICE) were developed according to methods outlined in the document Guideline Development Process – Information for National Collaborating Centres and Guideline Development Groups. The methods were originally created for clinical guidelines and were adapted for the development of public health guidance. The work was supported by two public health collaborating centres in the United Kingdom (UK) that searched for and synthesized evidence for a range of subtopics, resulting in a series of public health evidence reviews. According to NICE, each evidence review did the following:

  • Critically appraised the included studies
  • Identified what components are effective for which groups and in which settings
  • Identified the inputs and process issues that had an impact on the development and delivery of effective interventions

For each question, the highest possible level of evidence was selected. The highest rating for quality of evidence was given to high-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias. Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias were also rated very highly. If a systematic review, meta-analysis, or RCT related to the question being asked existed, studies of a weaker design were ignored. Where the evidence base was limited, questions were addressed by identifying published expert narrative reviews by a project team and/or guidance development group and which formed the basis of discussion papers written either by that or by a member of the development group. Relevant information for each included study was summarized in evidence tables, evidence statements, and narrative summaries.

Regarding the quality of the evidence for these recommendations, NICE found that:

Only a few public health RCTs met the NICE critical appraisal criteria in full and it was rarely possible to be certain that, as required by the NICE critical appraisal processes, the overall effect was due to the study intervention. Studies often lacked (or failed to report) a description of the randomization process, concealment allocation and/or an intention to treat (ITT) analysis.

As the quotation above indicates, the evidence base to support public health interventions to improve healthy eating and active living is not well developed. There are several challenges associated with developing a high-quality public health evidence-base, which is inherently interdisciplinary in nature and based on evidence generated from the application of mixed methods. These include but are not limited to difficulties with implementing RCTs at the community level, insufficiently long time scales for judging the effectiveness of interventions, lack of consensus about appropriate assessment indicators, and failure to properly evaluate interventions. As a result, and also in recognition of the valuable contribution that personal experience and training can make, a combination of evidence and expert opinion was used to formulate the recommendations for public health practice contained in this report.

Quality Appraisal of the NICE Evidence-based Guidance Document

The Appraisal of Guideline Research and Evaluation (AGREE) Instrument was used to rate the NICE guidance. The purpose of the AGREE Instrument is to provide a framework for assessing guideline quality, which includes judgements about the methods used for developing the guidelines, the content of the recommendations, and the factors linked to their uptake.

The NICE guidance was assessed with the AGREE instrument by two Program in Evidence-based Care (PEBC) staff members and one working group member. The results of the ratings for each reviewer are presented in Appendix 4 in the original guideline document. The document was rated highly in the domains of Scope and Purpose, Rigour of Development, Clarity and Presentation, Applicability, and Editorial Independence. Overall, the quality ratings were favourable, with scope and purpose, rigour of development, and applicability domains being particularly strong.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Adaptation

The adaptation process followed the ADAPTE methodology, a systematic approach to adapting guidelines developed in one jurisdiction for use in new cultural and organizational contexts. Twenty of the 23 steps in the method were applied. The three steps that were not completed included Step 20, endorsement by professional bodies most closely connected to the guideline topic; Step 21, consultation with source guideline developers; and Step 23, plan for aftercare of the adapted guideline.

In order to distribute the project workload, the relevant Ontario Public Health Standards (OPHS) Chronic Disease Prevention and Child Health Requirements were divided among three working groups (see Appendix 2 in the original guideline document), according to the following topics and under the stewardship of the Expert Standing Committee:

  1. Schools and Workplaces
  2. Healthy Policy and Capacity Building
  3. Public Awareness and Population Skill-building

The working groups used the OPHS as a framework for organizing the recommendations of the guidance document chosen for adaptation, in order to produce a draft set of adapted recommendations. OPHS requirements for chronic disease prevention and child health were used as headings, and the recommendations from the chosen document were mapped onto them. Each working group assessed the acceptability and applicability of the mapped recommendations for the Ontario context. The groups created new recommendations as needed to fill any gaps that were identified or modified the language of the recommendations to make them consistent with the Ontario context. In order to support group opinions, other evidence that was not captured in the chosen guidance document or the environmental scan was brought forward as needed by members of the working groups. In order to address any overlap in the subject matter between groups, and to ensure the consistency of the draft recommendations, the Expert Steering Committee, which included the working group leads, reviewed all the recommendations prior to the start of the consultation process.

The process of adapting the National Institute for Health and Clinical Excellence (NICE) recommendations occurred over the summer of 2008. The three working groups met separately several times in teleconference and assessed each recommendation for its acceptability and applicability (ADAPTE Step 15: Tool 15) for the Ontario context. The adaptation process resulted in some additional resources being brought forward by the working group members (see Table 1 in the original guideline document). These documents were utilized according to the opinions of the working groups to modify or create new recommendations to fill identified gaps. For example, the NICE guidance document referenced United Kingdom (UK) standards for healthy eating and physical activity. Working group #3 recommended modifying these recommendations to Canadian standards, using Eating Well with Canada's Food Guide and Canada's Physical Activity Guide to Healthy Active Living. Thus, resources gathered nonsystematically (i.e., on the basis of "opinion of the working group") were used when deemed necessary in order to supplement the evidence-based NICE guidance located through the environmental scan.

The Research Coordinator made additional revisions to the recommendations, which were then distributed again within each working group for approval. When each group had approved its own recommendations, all were compiled and assessed by the working group leads for cohesiveness and completeness. The draft recommendations were approved by all three working group leads and by the Expert Steering Committee in October 2008.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Stakeholder Consultation

A two-round stakeholder consultation was organized to obtain feedback on the recommendations from the targeted users of the Project in Evidence-based Primary Prevention (PEPP) guideline and to ensure that the recommendations were implementable and appropriate for practice in Ontario. Participating groups, organizations, and individuals were identified by the Expert Steering Committee. The stakeholder consultation was conducted electronically in order to reduce geographic barriers to participation. To solicit feedback on the draft recommendations and raise stakeholder awareness, an online survey tool was used in the first round of the process, and an e-mailed portable document format (PDF) form was used in the second round.

Round 1

The first round of the two-round consultation process took place from December 17, 2008 to January 18, 2009. As target users of the guideline, all 36 health units in Ontario were surveyed. Fifteen other Ontario organizations that were identified by the Expert Steering Committee (see Appendix 5 in the original guideline document) as potential users of the guideline, or stakeholders with an interest in the implementation of the guideline, were also surveyed.

The participants were asked to rate their level of agreement with each of the 50 recommendations, using a 5-point Likert response scale (1. strongly disagree, 2. disagree, 3. neither agree nor disagree, 4. agree, 5. strongly agree). An opportunity to comment on each recommendation and on the overall survey was also provided. The original 50 draft recommendations that were included in the Round 1 stakeholder consultation are available from the Program in Evidence-based Care (PEBC) on request.

Stakeholders were asked to submit one survey per organization and were free to complete the survey as a group.

Round 2

The second round of the consultation process took place between March 16, 2009 and March 30, 2009. The original plan for the second round was to repeat the methods used in Round 1, using the Likert scale to assess the level of stakeholder agreement with each individual recommendation, revised using the Round 1 feedback that was received from stakeholders. In light of the high level of agreement with the recommendations in the first round (see Results section and Appendix 6 in the original guideline document), the decision was made to change the Round 2 methodology from a consultation on each individual recommendation to an opportunity to comment on each section (e.g., Priority Populations) of the Recommendations and on the guideline as whole. Thus, Round 2 was reconfigured to give stakeholders an opportunity to view and validate the changes that had been made in response to Round 1 feedback. A portable document format (PDF) form was used in this round in order to make it easier for respondents to save and share the survey.

External Review

During the guideline development process, five targeted peer reviewers (including academic researchers and public health officials) from Ontario were identified by the Expert Steering Committee. Several weeks prior to completion of the draft report, the nominees were contacted by email and asked to serve as reviewers. Five reviewers agreed, and the draft report and a questionnaire were sent via email for their review. The questionnaire consisted of items evaluating the methods, results, and interpretive summary used to inform the draft recommendations and whether the draft recommendations should be approved as a guideline.

Written comments were invited. The questionnaire and draft document were sent out on August 26, 2009. Follow-up reminders were sent at two weeks (email) and at four weeks (telephone call). The PEPP Panel reviewed the results of the survey. All five reviewers replied by October 14, 2009.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC) and the Program in Evidence-based Care (PEBC): The Ontario Public Health Standards (OPHS) served as the organization framework for reporting the following recommendations. A description of the OPHS standard relevant for each recommendation, as well as the source used to inform the recommendation, is presented in the original guideline document. The majority of the recommendations were adapted from another practice guideline (see "Adaptation" field for more information).

Foundational Standard

Statistical analysis techniques that control for contextual as well as individual characteristics (multilevel and hierarchical modelling techniques) are appropriate and recommended in research studies investigating public health interventions. Quantitative research studies that focus solely on individual-level differences are not appropriate.

Elementary and Secondary Schools

  1. Public health professionals should support and encourage school administrators, in collaboration with school staff, parents, and students, to assess the whole school environment, including recess and before and after-school activities, to ensure that the ethos of all school policies helps children and youth to eat a healthy diet, be physically active, and maintain a healthy weight in accordance with public health resources and capacities based on best practices. This also includes policies, guidelines, and practices related to the Foundations for a Healthy School: high-quality instruction and programs, a healthy physical environment, a supportive social environment, and community partnerships.
  2. If short-term interventions and one-off events are carried out, they must be embedded in a whole school approach that is consistent with the Foundations for a Healthy School. Short-term interventions and one-off events are insufficient on their own.
  3. Public health professionals should work in partnership with schools to provide training and support for administrators, teachers, support staff, cafeteria or catering staff, parent and student leaders, and food service and other volunteers, regarding healthy-school policies or initiatives and their implementation. Key concepts are healthy eating, active living, and sensitivity training, which include an appreciation of the impact that adult role models may have on students.
  4. Public health professionals should work in partnership with schools to promote the eating of lunches by children and youth in a pleasant, sociable, and safe school environment. Younger children should be supervised at mealtime and, if possible, school staff should eat with the children in order to provide positive role modelling and monitor the eating environment. Adequate time should be provided for eating lunch.
  5. Public health professionals should encourage schools to establish partnerships and link with organizations and professionals, including those involved in local strategies, to promote physical activity and healthy eating for children and young people. The messages and values of these partners should be consistent with public health policy.
  6. Public health professionals should advocate, through provincial and board-level coalitions and partnerships with educators and school boards, for physical education specialists to provide physical education instruction in schools and/or supervise generalist teachers in physical education classes. Generalist teachers who are leading physical education classes should have access to mentoring from specialists to maximize the benefits of physical activity instruction that students receive.
  7. Public health professionals should encourage school staff delivering physical education, sport, and physical activity to promote inclusive activities that children and youth find enjoyable and can participate in outside school hours, and throughout their adult lives. This includes opportunities to participate in structured and unstructured, lower cost, non-competitive sports and recreational activities. Children's confidence and understanding of why they need to continue physical activity throughout life should be developed as early as possible.
  8. Staff and stakeholders planning physical activity and healthy eating related programs or policy interventions should involve children and youth in the planning and assess potential barriers and facilitators to the planned interventions (i.e., ensuring interventions are safe, accessible, affordable, and appealing).
  9. All programs aimed at improving eating habits and physical activity levels should take into account mental well-being, and emphasize healthy growth and development, since unintended harmful consequences may occur as a result of overweight/obesity prevention initiatives (e.g., over-emphasis on weight, children adopting the healthy eating messages in extreme ways). Programs should address such topics as screen time use, media literacy, dealing with bullying, and building positive self-esteem, and fit within a whole school approach.
  10. Where possible, parents should be directly involved in school-based healthy eating and active living interventions through, for example, special events, after-school activities, newsletters, and information that is consistent with guidelines that are being followed by the schools as outlined in Foundations for a Healthy School. Public health professionals should encourage parental involvement on committees, including school councils, that make decisions about policy and supportive environments for healthy eating and active living.

Post-Secondary Schools

Public health should work to establish and maintain partnerships with student health services in post-secondary educational settings to promote a comprehensive health promotion approach throughout the institution. This includes the promotion of healthy eating and active living (e.g., providing consistent information to the student population or priority subpopulations about food skills and healthy eating; coping with stress, including managing the transition to the post-secondary setting life skills; and opportunities for physical activity).

Workplaces

  1. Public health professionals should promote the use of situational assessments to create workplace health promotion programs that include awareness-raising activities, education/skill-building opportunities, environmental supports, and policy options.
  2. Public health professionals should promote interventions that take an interdisciplinary approach, with the following core principles:
    • Senior management involvement, including engaging senior management "champions"
    • Active engagement of staff through participatory planning
    • Primary focus on employees' needs, addressing the causes of behaviour that contributes to increased risk of chronic diseases
    • Optimal use of on-site resources and coordination with departments such as Occupational Health and Safety and Human Resources
    • Integration and alignment of workplace health policies with the organization's corporate mission, vision, and values, supporting both short and long-term goals
    • Recognition that a person's health is determined by an interdependent set of factors
    • Tailoring to the unique features of each workplace environment
    • Evaluation, including a clearly defined and realistic set of process and outcome measures
    • Long-term commitment
    • Involvement of employees' families, where possible, as social support is a recognized condition of creating and sustaining healthy behaviours
  3. As identified in the situational assessment, public health professionals should provide support for workplaces that are ready to implement a sustained workplace health promotion program. This program needs to be part of an overall comprehensive strategy that will encourage employees to be more physically active and eat well, with the objective of improving their sense of well-being. Where appropriate and feasible, this should be provided on the work premises. It should provide links to services that already exist in the community (e.g., services of Personal Fitness and Lifestyle Consultant, registered dietitians), advice, and other information or resources.
  4. Public health professionals should support workplaces that are developing healthy eating initiatives. These initiatives, as part of a workplace health promotion program, should be sustained and include the following components:
    • Actions to improve food and beverage choices in the workplace, including cafeterias, catering and vending machines, should be supported by tailored educational and promotional programs such as a behavioural intervention and environmental changes.
    • Active and continuous promotion of healthy food and beverage choices in cafeterias, catering, vending machines, and shops for staff and clients, according to existing provincial healthy eating standards/guidelines. Longer, interactive behavioural intervention efforts (e.g., self-assessment materials, professionally led direct education and skill-building workshops) are better than one-time events or more passive efforts such as the use of printed materials.
    • Supportive environmental changes such as heavily advertised point of purchase information strategies and/or changes in food availability or cost, to encourage healthier eating.
    • Physical environments that promote healthy eating, such as the availability of a designated lunch room, and appliances such as a refrigerator and microwave, as well as nutrition guidelines/policies (e.g., for foods served at meetings and functions).
  5. For such a program to be effective, commitment from senior management, enthusiastic catering management, a strong occupational health lead, links to other on-site workplace health promotion initiatives, and supportive pricing policies that subsidize healthier food and beverage choices are likely to be needed.
  6. Healthy weights initiatives that focus on healthy eating and physical activity as part of a workplace health promotion program should be sustained and include a positive health education approach, which fosters motivation in the form of workplace support. Educational counselling about weight loss or "controlling your weight" is not recommended as an overall workplace strategy because the treatment of obesity requires a very specialized multidisciplinary approach in a supervised clinical setting after a thorough and appropriate clinical assessment.
  7. Physical activity initiatives as part of a workplace health promotion program should be sustained and may include the following components:
    • Incentive schemes such as flexible hours, and practices and policies that encourage employees to walk, bike, or use other modes of transport involving physical activity.
    • Where possible, encourage employees to move around more at work (for example, by walking to external meetings) and support recreational opportunities such as lunchtime walks and the use of local recreation facilities.
    • Information about safe walking and biking routes and encouragement for employees to take short walks during work breaks.
    • The effective dissemination of information (including written information) on how to be more physically active and on the health benefits of such activity. This could include information on local opportunities to be physically active (both within and outside the workplace) tailored to meet specific needs, for example, the needs of shift workers.
    • Ongoing advice and support to help employees plan how they are going to increase their levels of physical activity.
    • Information on where to access confidential, independent appraisal for the evaluation of physical fitness administered by a certified Personal Fitness and Lifestyle Consultant.
    • Signs at strategic points and written information to encourage employees to use the stairs rather than elevators if they can. Environmental improvements in stairwells, such as redecoration, motivational signs, and music may increase stair use. Posters alone may be ineffective or effective only while the posters are in place.
    • A supportive physical environment such as providing showers and secure bike parking.
    • Encouraging employees to set goals and self-monitor on how far they walk and bike.

Food Premises

With support from provincial organizations, public health professionals should encourage stores, supermarkets, restaurants, and cafes to promote healthy eating choices such as increased fruit, vegetable, and whole grain consumption and decreased overall saturated and trans fat intake (i.e., choices that are consistent with Eating Well with Canada's Food Guide). Strategies should include information such as signs and posters at the point of purchase and encouraging these food premises to adopt competitive pricing and motivating positioning of healthier products.

Municipalities

  1. Public health should work with municipalities and industry, other levels of government, and voluntary organizations to create and manage more safe spaces for both spontaneous and planned physical activity, considering that enhanced access to space for physical activity can increase physical activity levels. This would include:
    • Providing facilities such as cycling and walking routes, cycle parking, safe play areas, and area maps.
    • Making streets cleaner and safer, through measures such as traffic calming, pedestrian crossings, cycle routes, lighting, and walking schemes.
    • Environmental improvements to buildings and spaces that encourage people to be more physically active (e.g., positioning and signing of stairs, entrances, and walkways).
    • Targeted behavioural change programs, which appear to change travel behaviour of motivated groups. Such programs should consider in particular people who require tailored information and support, especially inactive, vulnerable (e.g., low income; disabled) groups.
    • Auditing the needs of local users to engage all potential local partners and establish local ownership.
  2. Public health should promote policy and environmental supports that increase supply and access to healthier foods and beverages in vending machines and snack bars in municipal recreation centres, arenas, and at municipally run events. Successful sales of healthy options can be facilitated by user involvement; appropriate, highly visible location and ongoing regular provision (e.g., making sure that vending machines are in working order); promotional signage; and competitive pricing relative to less healthy options.
  3. With information and advice from public health, municipalities should be encouraged to lead by example in developing healthy eating and active living policies within their own workplaces, and within the programs that they deliver to the public, given their potential for influence the local community. Supports within the workplace should include the policies and activities outlined above in the section above, "Workplaces."
  4. Public health should collaborate with municipal governments, retailers, and community organizations to improve access to healthy food. Strategies should be appropriate for the local context and take advantage of local opportunities. Examples include community-shared agriculture and community gardens and emphasizing more accessible food sources (e.g., local farmers' markets).
  5. Public health should encourage municipal partners, including planning, transport, and leisure services, to engage with the local community to identify environmental barriers to healthy eating and active living, including barriers experienced by vulnerable (e.g., low income, disabled) populations. This should include:
    • An assessment, including an audit of the food environment, developed collaboratively with the board of health and local residents, businesses, and institutions to engage all potential local partners and establish local ownership.
    • An assessment (ideally by doing a health impact assessment) of the impact of municipal policies on the ability of communities to create supportive environments in which individuals can be physically active and eat a healthy diet. The needs of population subgroups should be considered because barriers may vary by, for example, age, gender, social status, ethnicity, religion, and whether an individual has a disability.
    • Barriers identified in this way should be addressed.
  6. Public health professionals should advocate for transportation policy initiatives. Policy should include standards for access and availability of public transportation, opportunities for active transportation, and plans that link various modes of active and nonactive transportation and create hubs. Municipality-wide changes that make it easier and safer to walk, cycle, and use public transport have the potential to make active transport more appealing to local users.

Improving Capacity of Community Partners

  1. All community programs to increase activity levels and encourage healthy eating should address the concerns of local people (i.e., the targeted community) from the outset. A situational assessment should be used to determine relevant programming, and interventions should be context specific. Concerns identified by the situational assessment could include the availability of services or confusion over mixed messages in the media about weight, diet, and physical activity.
  2. Interventions to encourage healthy eating and physical activity should be multifaceted (for example, awareness raising, education and skill building, environmental supports, and policy development) and part of a comprehensive health promotion strategy.
  3. Public health professionals should use their expertise in communications, data management, program planning, development, delivery, surveillance, monitoring, and evaluation to advise and collaborate with family health teams and community health centres on initiatives related to healthy eating and active living.
  4. Public health should work with community partners and the province to advocate for and develop the capacity to implement local programs that address multiple chronic diseases and promote good health. This includes building on existing or developing programs initiated by other groups or organizations.
  5. Family-based interventions delivered by community agencies to encourage healthy eating and/or increase physical activity levels should provide ongoing, tailored support and incorporate a range of behaviour change techniques. Programs should have a clear aim to improve healthy eating practices and physical activity levels. Public health can provide resources (e.g., train the trainer, targeting of specific groups) and sit at the planning and evaluation tables for community agencies such as community health centres and family health teams.

Links to Community Programs and Services

  1. As appropriate, public health should refer people who have any queries or concerns about their—or their families'—eating habits, physical activity levels, or weight to an in-house or community health professional such as a registered dietitian, physical activity specialist, health promoter, public health nurse, or general practitioner. As appropriate, referrals should be made to family health teams, community health centres, diabetes education centres, or existing province-wide programs.
  2. Population health communications and community-wide interventions to increase physical activity and improve nutrition should be tailored to people's preferences and circumstances and should aim to improve people's belief in their ability to change (for example, by verbal persuasion, modelling exercise behaviour, and discussing positive effects). Interventions to increase physical activity should focus on activities such as walking that fit into people's everyday lives. Ongoing support, including appropriate written materials, should be given in person or by phone, mail, Internet, or by primary care practitioners.
  3. Public health professionals should support and promote behavioural change programs along with tailored advice (e.g., phone intake or web-based) to help people who are motivated to change to improve eating habits or become more active, for example, by walking or cycling instead of driving or taking the bus.
  4. Public health professionals should advise that adults follow Eating Well with Canada's Food Guide and Canada's Physical Activity Guide, which might make it easier to maintain a healthy weight. Adults should also be encouraged to maintain a healthy relationship with food, body weight, and body shape.
  5. Public health professionals should also encourage parents and caregivers to use Eating Well with Canada's Food Guide and Canada's Physical Activity Guide to help children establish healthy behaviours and maintain or work towards a healthy weight. As well, significant adults should be positive role models for children and youth with respect to their own perceptions of body weight and shape, model a healthy relationship with food, and ensure that no teasing or disparaging comments are made regarding their child's body weight by family members.

Priority Populations

  1. Public health professionals should work with primary care practitioners to provide information as needed on healthy eating, and physical activity to people at times when weight management is more difficult, including during and after pregnancy, at the time of menopause, and while stopping smoking, and to support the needs of other locally identified priority populations.
  2. Interventions to support smoking cessation should provide information and advice on long-term weight management, in particular by encouraging physical activity and healthy eating.
  3. Public health should advocate for and support food skills training programs in a variety of settings, including school boards, parks, and recreation and social services. Training should include menu planning, food selection, safe food handling, healthy food preparation, storage, and serving. Priority populations that may benefit from food preparation skills training are wide ranging and may include children, youth, young single adults, parents, newcomers to Canada, women who are pregnant or postpartum, and individuals of various socioeconomic statuses. Food skills programs for caregivers of children should include information on how they can encourage young children to eat healthy foods and develop a healthy relationship with food.

Public Awareness

  1. Public health professionals should adopt a comprehensive approach to encourage public awareness of healthy eating, daily physical activity, and positive self-esteem, which includes healthy relationships with food, positive attitude towards weight and body shape, media literacy, and resiliency factors.
  2. Community-based interventions might include awareness-raising promotional activities, but these should be part of a longer term, multicomponent intervention rather than one-off activities and should be accompanied by targeted follow-up with priority populations.

Supportive Environments for Breastfeeding and Child Health

  1. Public health should encourage supportive environments for lactating mothers in the community and workplace that include flexible work schedules, safe and clean spaces for milk expression, and safe storage for expressed breast milk. All public health agencies should develop and maintain their own internal breastfeeding policy and ensure all staff are aware of and understand the relevance of that policy.
  2. Public health should promote healthy eating and physical activity as priorities for early learning and childcare facilities such as nurseries and daycares by:
    • Minimizing sedentary activities during play time, and providing regular, structured and unstructured opportunities for enjoyable active play and physical activity sessions.
    • Implementing the Ontario Day Nurseries Act requirements for physical activity, including activities designed to promote gross and fine motor skills appropriate for the developmental level of the child, and ensuring that each child over thirty months of age that is in attendance for six hours or more in a day plays outdoors for at least two hours each day, weather permitting.
    • Implementing Ontario Day Nurseries Act requirements for nutrition.
  3. Strategies to ensure healthy eating and active living in nurseries and daycares should seek to involve parents in a significant way. This can improve parental engagement in active play with children and children's dietary intake.

Breastfeeding: World Health Organization/United Nations International Children’s Emergency Fund (WHO/UNICEF) Baby-Friendly Initiative

Public health should advocate for the incorporation of UNICEF Baby Friendly principles and practices as a proactive and comprehensive approach to achieving healthy weights for the people of Ontario.

Breastfeeding: Other Support

  1. Public health programming should support mothers in exclusively breastfeeding their children during the first six months of life, with the continuation of breastfeeding for two years and beyond, with the introduction of nutrient-rich complementary foods at six months, and with particular attention to iron. Public health should also respect a woman's decision to feed her child with a breast milk substitute (e.g., infant formula).
  2. Public health should advocate for and support community-based and partner-driven programs for breastfeeding families. It is important to provide immediate, intensive postpartum support in person.

Breastfeeding: Priority Populations

Priority populations for public health should include Aboriginal women living off-reserve and women and adolescent girls experiencing poverty, poor nutrition, teen pregnancy, social and geographic isolation, adjustment to a recent arrival in Canada, or current or past alcohol or substance use and/or family violence, in addition to other locally identified groups.

Family-based Interventions

Families of children and young people identified as being at high risk of eating behaviours that could lead to obesity should be offered ongoing support from an appropriately trained and regulated health professional. Individual as well as family-based interventions should be considered, depending on the age and maturity of the child. Public health should play a role in advocating for these supports.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations are supported largely by one guideline that was based on systematic reviews of the public health literature.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Over time, if implemented, these strategies should reduce barriers to healthy eating and active living in the environments in which individuals learn, live, and work and ultimately, reduce the risk of certain cancers and other chronic diseases.
  • Implementation of these strategies will make it more likely that Ontario adults and children will live in an environment that promotes good health in their schools, communities, and workplaces.
Potential Harms

Unintended harmful consequences may occur as a result of overweight/obesity prevention initiatives (e.g., over-emphasis on weight, children adopting the healthy eating messages in extreme ways).

Qualifying Statements

Qualifying Statements
  • The World Cancer Research Fund (WCRF) found convincing evidence for a decreased risk of pre- and postmenopausal breast cancer and a probable decreased risk of ovarian cancer among women who had breastfed their babies. Examining this link is beyond the scope of this report, because the general mechanisms through which lactation could plausibly protect against cancer are not related to obesity but rather occur through hormonal effects or changes to breast tissue.
  • This guideline does not make recommendations regarding specific program or policy interventions but instead focuses on strategies that will support the selection and implementation of effective programs. In the Discussion section of the original guideline document, several other sources of information regarding programs or tools that have been appropriately evaluated are identified. It is beyond of the scope of this guideline to address the operational capacity of public health departments in Ontario to implement these recommendations.
  • Care has been taken in the preparation of the information contained in this report. Nonetheless, any person seeking to apply or consult the report is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer Care Ontario makes no representation or guarantees of any kind whatsoever regarding the report content or use or application and disclaims any responsibility for its application or use in any way.

Implementation of the Guideline

Description of Implementation Strategy

This guideline suggests strategies for Ontario public health units and for other stakeholders working in chronic disease prevention in Ontario. The question of how best to implement these recommendations was raised by the developers of this document and by stakeholders, and the implementation of public health policy recommendations is a common concern. Policymakers have described their difficulties in responding to recommendations, citing a lack of guidance on how to translate public health and clinical evidence about obesity control into meaningful policies.

A systematic approach to program planning is recommended. The program planning steps below are a starting point for implementing this guideline. Some or all of these steps can be used to identify and describe the health issue of interest and develop a comprehensive program plan that addresses the problem. The Handbook of Obesity Prevention presents a framework for thinking through evidence needs for obesity prevention, and includes the following components of an evidence-based obesity prevention program:

  1. Build a case for action on obesity (Why should we do something about obesity?)
  2. Identify the contributing factors and point of intervention (What are the causative and protective factors that could potentially be targeted by interventions?)
  3. Define the range of opportunities for action (How and where could we intervene?)
  4. Evaluate potential interventions (what are the specific, potential interventions and their likely effectiveness?)
  5. Select a portfolio of policies, programs and actions (What is a balanced portfolio of initiatives that is sufficient to prevent increases in obesity?)

These questions should be considered in the local context, taking into consideration the populations to be targeted and the availability of resources for program development. This guideline addresses steps ii. and iii. in the list above. Steps iv. and v. refer to choosing specific interventions and programs and are outside the scope of this project. It is anticipated that this gap will be filled by existing tools that have been developed by organizations such as health-evidence.ca (http://www.health-evidence.ca/ External Web Site Policy), which is designed to provide quality research evidence to decision makers, the Public Health Agency of Canada's Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention (http://cbpp-pcpe.phac-aspc.gc.ca/ External Web Site Policy), and Towards Evidence-Informed Practice (http://teip.hhrc.net/ External Web Site Policy), as well as other tools that are in development such as the National Collaborating Centre for Methods and Tools (http://www.nccmt.ca/ External Web Site Policy) online program planning tool for public health and their registry of methods and tools for knowledge translation in public health. Furthermore, there are plans for guidance documents for the Ontario Public Health Standards (OPHS) that will name specific evidence-based tools that can be used to implement this guideline.

As noted in feedback to the draft recommendations, and in documents that have been published previously, another necessary component for the implementation of this guideline is provincial support. This support would include a clear vision at the provincial level; investment in the health promotion system, including human, financial and material resources; and the development of a comprehensive health promotion infrastructure.

It is also important to note that the Foundational Standards of the OPHS underpin these recommendations. The foundational principles are:

  • Need (tailoring programs and services to address needs that are influenced by the contexts of local communities)
  • Impact (influencing broader societal changes that reduce health inequities by coordinating and aligning programs and services with those of other partners and using comprehensive approaches that employ a multifaceted range of activities)
  • Capacity (striving by boards of health to achieve the needed capacity and resources required to meet the OPHS standards)
  • Partnership and Collaboration (extensive partnerships within the health sector and other sectors)

The OPHS Foundational Standards promote evidence-based practice through assessment, surveillance, research and knowledge exchange, and program evaluation. Adopting the Foundational Standards should help to improve the public health knowledge base and evidence-based decision making in Ontario.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Garcia J, Beyers J, Uetrecht C, Kennedy E, Mangles J, Rodrigues L, Truscott R, Expert Steering Committee of the Project in Evidence-based Primary Prevention. Healthy eating, physical activity, and healthy weights guideline for public health in Ontario. Toronto (ON): Cancer Care Ontario (CCO); 2010 Mar 17. 52 p. (PEBC report; no. 23-1).  [37 references]
Adaptation

This guideline was adapted from the following source:

  • National Institute for Health and Clinical Excellence (NICE); National Collaborating Centre for Primary Care. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. London: National Institute for Health and Clinical Excellence; 2006 Dec. (http://www.nice.org.uk/CG43 External Web Site Policy)
Date Released
2010 Mar 17
Guideline Developer(s)
Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]
Guideline Developer Comment

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Source(s) of Funding

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Guideline Committee

Expert Steering Committee of the Project in Evidence-based Primary Prevention

Composition of Group That Authored the Guideline

Committee Members: Dr. John Garcia, PhD (Expert Steering Committee [ESC] Chair as of July 2008), Director, Knowledge Exchange and Systems Evaluation, Ontario Tobacco Research Unit, Senior Consultant, Preventive Oncology, Cancer Care Ontario (CCO); Ms. Deb Keen (ESC Chair until June 27, 2008), Canadian Partnership Against Cancer; Ms. Joanne Beyers, Registered Dietitian, Public Health Research, Education and Development (PHRED) Program, Sudbury & District Health Unit; Dr. Melissa Brouwers, PhD, Director, Program in Evidence-Based Care (PEBC), CCO; Ms. Erica Di Ruggiero, MHSc, RD, PhD (c), Past Chair, Ontario Collaborative Group on Healthy Eating and Physical Activity; Volunteer, Canadian Cancer Society, Ontario Division, Associate Director, CIHR-Institute of Population and Public Health; Ms. Erin Kennedy, Research Coordinator, PEBC, CCO; Dr. Sheila McNair, PhD, Assistant Director, PEBC, CCO; Ms. Danielle Paterson, Senior Advisor, Prevention, Canadian Cancer Society, Ontario Division; Ms. Connie Uetrecht, Chair, Ontario Chronic Disease Prevention Alliance, Executive Director, Ontario Public Health Association; Ms. Pegeen Walsh, Director, Chronic Disease Prevention, Ontario Ministry of Health Promotion

Financial Disclosures/Conflicts of Interest

No conflicts of interest have been reported by the developers of this guideline.

Guideline Status

This is the current release of the guideline.

The PEBC report over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site External Web Site Policy for details on any new evidence that has emerged and implications to the guidelines.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Cancer Care Ontario Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 30, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please refer to the Copyright and Disclaimer Statements External Web Site Policy posted at the Program in Evidence-based Care section of the Cancer Care Ontario Web site.

Disclaimer

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