A total of 65 sources of evidence were included in the review, representing 34 unique nutrition interventions (13–16,21,22,35–93) (Figure 1). Of these, 14 (41%) were implemented in a single school and 20 (59%) were implemented in more than one school. Nine interventions (26%) included each of the four components of CSH, and five interventions (15%) included the four supplementary components identified as important in school-based nutrition interventions for Indigenous children. Four interventions (12%) included all eight components. Twenty-four interventions targeted First Nations populations (70%), four targeted Inuit populations (12%), and one targeted Métis populations (3%). One intervention (3%) targeted both First Nations and Métis populations. Four interventions (12%) did not specify a target group; rather, they broadly indicated being implemented in Indigenous or Aboriginal communities. Fifteen interventions (44%) were implemented in provinces in Eastern Canada (Newfoundland and Labrador, New Brunswick, Nova Scotia, Ontario, Prince Edward Island, Quebec), 13 interventions (38%) in provinces in Western Canada (Alberta, British Columbia, Manitoba, and Saskatchewan), and four (12%) in the Territories (Northwest Territories, Yukon, and Nunavut). One was a national intervention in several provinces (3%), and one was in an unspecified location (3%).
Findings related to the four components of CSH (social and physical environments, teaching and learning, school policy, and partnerships and services) and the four supplementary components of Indigenous school-based nutrition interventions that were examined (cultural content, Indigenous control and ownership, funding source, evaluation) are described in detail below.
Components of CSH
Social and physical environment
Thirty-three interventions (97%) included one or more social and physical environment component. Seven interventions (21%) contributed to the social environment by providing healthy eating messages in newsletters or websites, or by displaying posters in the school that promoted healthy eating. For example, the Hillside Elementary School and Greenwood Elementary School Active Schools programs displayed posters in classrooms that promoted healthy lifestyles and sent newsletters home that included healthy recipes (64). To encourage both healthy relationships and healthy eating, three interventions (9%) included community feasts. Three interventions (9%) offered student cooking classes or community kitchens, where children learned about healthy eating, practiced cooking skills, and enjoyed nutritious meals. In addition, four interventions (12%) included a peer-mentoring component in which younger students learned about healthy eating from older peers. For example, the Aboriginal Youth Mentorship Program (AYMP) was an after-school peer mentoring program that included healthy snack and nutrition education components (40,44). Staff modelling was also recommended by one intervention (3%), which specifically encouraged staff to portray and model healthy eating and positive attitudes towards healthy eating.
Most interventions also included physical components that increased students’ access and exposure to healthy food choices. The majority of interventions (n=25, 74%) offered food programs, with some of them offering breakfast, lunch, and snack (n=6, 24%), breakfast solely (n=4, 16%), breakfast and snack (n=1, 4%), breakfast and lunch (n=3, 12%), lunch solely (n=1, 4%), lunch and snack (n=1, 4%), and snack solely (n=8, 32%). One intervention (3%) mentioned offering student nutrition programs but did not specify the meal(s) that were included. Furthermore, three interventions (9%) mentioned student access to a canteen stocked with healthy snacks, and two schools (6%) had vending machines with healthy options. Six interventions (18%) included a school or community garden, and five interventions (15%) included a nutrition awareness campaign or contest. For example, Elsipogtog First Nation School in New Brunswick hosted a healthy snack challenge, in which students who ate a fruit or vegetable during snack time were entered into a draw and had a chance to win a fruit basket (43).
Teaching and learning
One or more teaching and learning components were used in 19 interventions (56%). Fifteen interventions (44%) included a classroom education component in which discussions of healthy food choices were incorporated into the curriculum. The Kahnawake Schools Diabetes Prevention Project (KSDPP) in Quebec, for example, implemented a comprehensive education program for diabetes prevention that included lessons on balanced meals and healthy snacks, the benefits of healthy eating, factors that influence eating habits, and food label reading (65,71). Two interventions (6%) incorporated Indigenous land-based learning (i.e., hunting and fishing) into the curriculum. Four interventions (12%) offered a gardening program in which students learned to plant and harvest vegetables and fruits in the community or school gardens. Finally, three interventions (9%) offered professional development opportunities to teachers and staff related to providing nutrition education.
Thirteen interventions (n=13, 38%) included a policy component; however, the scope and content of policies was highly variable. Five interventions (15%) banned or actively discouraged junk food items (e.g., high fat and high sugar foods) from being brought to school. For example, Chief Harold Sappier Memorial Elementary School in New Brunswick discouraged parents from packing foods like potato chips, candy, and pop in student lunches in an effort to eliminate junk food from the school environment (86). Four interventions (12%) included food policy guidelines that outlined appropriate foods to serve in school food programs or sell in school vending machines. For example, the Kashechewan snack program in Ontario included written guidelines that outlined categories and frequency of foods to be served in the school (47). Two interventions (6%) stated that they were compliant with national and/or provincial guidelines, and one intervention (3%) mentioned having a healthy food policy but did not provide any details about the policy content. Finally, the nutrition policy implemented as part of KSDPP targeted a wide range of social and environmental factors to promote healthy food choices, including recommendations for staff, classroom celebrations, and eating environments (58).
Partnerships and services
Twenty interventions (59%) included one or more partnerships and services component(s). Six interventions (18%) included a parent and community engagement component in which school nutrition activities were reinforced and supported by activities that engaged families and the community-at-large. For example, Yukon Food for Learning encouraged volunteer involvement in delivering school nutrition programs (90). Two interventions (6%) also specifically mentioned engaging with Elders – or persons recognized for their wisdom, experience, and knowledge – who played a role in delivering nutrition education curricula by sharing their knowledge of cultural activities and traditional foods.
Sixteen interventions (47%) included partnerships with local health and social organizations, local businesses, and national health promoting agencies. For example, Zhiiwapenewin Akino’maagewin: Teaching to Prevent Diabetes (ZATPD) in Ontario was implemented in partnership with several schools, local stores, and health and social services in order to extend its reach in the community (52,53,76). Three interventions (9%) also specifically connected with dietitians or nutritionists, who assisted in planning school food program menus or provided individualized counselling for staff, students, and parents.
Nineteen interventions (56%) included one or more cultural components. Ten interventions (29%) included traditional foods – such as bannock (a quick bread) and wild game meat – in the schools’ food programs or the education curriculum. Four interventions (12%) incorporated traditional Indigenous ways of learning, such as learning through observation and practice, storytelling, and role modeling. Six interventions (18%) mentioned making culturally appropriate adaptations to education curricula and/or having community members review education materials for cultural sensitivity and relevance. Cultural adaptations included using Indigenous characters in stories and incorporating traditional stories and foods in lessons.
Indigenous control and ownership
Twenty-one interventions (62%) included a component in which the local community was actively involved in developing, implementing, and/or evaluating interventions. Seven interventions (21%) included information regarding programs or services being community initiated, driven, and/or developed. For example, the National Aboriginal Nutrition Program followed a community-led approach in which key stakeholders – including teachers, school staff, parents, and community members – collaboratively coordinated school nutrition activities (36). Fourteen interventions (41%) specified using participatory models of research (i.e., participatory action research and community-based participatory research) in which academic researchers and community members worked in collaboration. For example, Kipohtakaw Education Centre in Alberta developed, implemented, and evaluated both a school nutrition policy and gardening intervention through a community-based participatory research approach involving an equitable collaboration between community members and University researchers (49,51,66,67,72,88,89).
Twenty interventions (59%) reported one or more sources of funding. Twelve interventions (35%) received funding from donations, sponsorships, or funding from diverse organizations (e.g., corporations, companies, and charitable foundations). Examples included the Heart and Stroke Foundation of Canada, the Danone Institute of Canada, Canadian Feed the Children, ONEXONE, and Breakfast for Learning. Nine interventions (26%) were supported by research grant funding, including the Canadian Institutes of Health Research and University Departments. Regional and federal funding (e.g., Health Canada’s First Nations and Inuit Health Branch, Yukon Government Department of Education, and the Health and Wellness fund through the Government of the Northwest Territories) supported six interventions (18%). Finally, one intervention (3%) was supported by the operational budget of the local school board.
Fourteen interventions (41%) performed evaluations to understand the feasibility of interventions, the barriers and enablers of their implementation, and/or their impact and outcome on student knowledge, behavior, and health. For example, the Sandy Lake Health and Diabetes Project (SLHDP) in Ontario completed two evaluations to determine changes in students’ knowledge, skills, and self-efficacy and behaviors related to diet by collecting anthropometric data and having students complete a questionnaires and dietary recalls (16,60).