The impact of 12 modifiable lifestyle behaviours on depressive and anxiety symptoms in middle adolescence: prospective analyses of the Canadian longitudinal COMPASS study.

BACKGROUND: Unhealthy lifestyle behaviours are becoming increasingly common and might contribute to the growing burden of mental disorders in adolescence. We examined the associations between a comprehensive set of lifestyle behaviours and depression and anxiety in middle adolescents. METHODS: School-based survey responses were collected from 24,274 Canadian high school students at baseline and 1-year follow-up (average age 14.8 and 15.8 years, respectively). Using linear mixed-effects models, we examined prospective associations of adherence to recommendations for vegetables and fruit, grains, milk and alternatives, meat and alternatives, sugar-sweetened beverages [SSB], physical activity, screen time, sleep, and no use of tobacco, e-cigarettes, cannabis, and binge drinking at baseline with the depressive and anxiety symptoms (measured by CESD-R-10 and GAD-7 scales, respectively) at follow-up. RESULTS: Adherence to recommendations was low overall, particularly for vegetables and fruit (3.9%), grains (4.5%), and screen time (4.9%). Students adhering to individual recommendations, particularly for meat and alternatives, SSB, screen time, sleep, and no cannabis use, at baseline had lower CESD-R-10 and GAD-7 scores at follow-up. Adhering to every additional recommendation was associated with lower CESD-R-10 (ß=-0.15, 95% CI -0.18, -0.11) and GAD-7 scores (ß=-0.10, 95% CI -0.14, -0.07) at follow-up. Assuming cumulative impact, this might translate into 7.2- and 4.8-point lower CESD-R-10 and GAD-7 scores, respectively, among students adhering to 12 vs. 0 recommendations over four years of high school. CONCLUSIONS: The results highlight the preventive potential of population-based approaches promoting healthy lifestyle behaviours, particularly those with the lowest prevalence, as a strategy to improve mental health in adolescence.

Delivering health promotion during school closures in public health emergencies: building consensus among Canadian experts.

School-based health promotion is drastically disrupted by school closures during public health emergencies or natural disasters. Climate change will likely accelerate the frequency of these events and hence school closures. We identified innovative health promotion practices delivered during COVID-19 school closures and sought consensus among education experts on their future utility. Fifteen health promotion practices delivered in 87 schools across Alberta, Canada during COVID-19 school closures in Spring 2020, were grouped into: 'awareness of healthy lifestyle behaviours and mental wellness', 'virtual events', 'tangible supports' and 'school-student-family connectedness'. Two expert panels (23 school-level practitioners and 20 decision-makers at the school board and provincial levels) rated practices on feasibility, acceptability, reach, effectiveness, cost-effectiveness and other criteria in three rounds of online Delphi surveys. Consensus was reached if 70% or more participants (strongly) agreed with a statement, (strongly) disagreed or neither. Participants agreed all practices require planning, preparation and training before implementation and additional staff time and most require external support or partnerships. Participants rated 'awareness of healthy lifestyle behaviours and mental wellness' and 'virtual events' as easy and quick to implement, effective and cost-effective, sustainable, easy to integrate into curriculum, well received by students and teachers, benefit school culture and require no additional funding/resources. 'Tangible supports' (equipment, food) and 'school-student-family connectedness' were rated as most likely to reach vulnerable students and families. Health promotion practices presented herein can inform emergency preparedness plans and are critical to ensuring health remains a priority during public health emergencies and natural disasters.

Causal and Associational Language in Observational Health Research: A Systematic Evaluation.

We estimated the degree to which language used in the high-profile medical/public health/epidemiology literature implied causality using language linking exposures to outcomes and action recommendations; examined disconnects between language and recommendations; identified the most common linking phrases; and estimated how strongly linking phrases imply causality. We searched for and screened 1,170 articles from 18 high-profile journals (65 per journal) published from 2010-2019. Based on written framing and systematic guidance, 3 reviewers rated the degree of causality implied in abstracts and full text for exposure/outcome linking language and action recommendations. Reviewers rated the causal implication of exposure/outcome linking language as none (no causal implication) in 13.8%, weak in 34.2%, moderate in 33.2%, and strong in 18.7% of abstracts. The implied causality of action recommendations was higher than the implied causality of linking sentences for 44.5% or commensurate for 40.3% of articles. The most common linking word in abstracts was "associate" (45.7%). Reviewers' ratings of linking word roots were highly heterogeneous; over half of reviewers rated "association" as having at least some causal implication. This research undercuts the assumption that avoiding "causal" words leads to clarity of interpretation in medical research.

Perceived changes in lifestyle behaviours and in mental health and wellbeing of elementary school children during the first COVID-19 lockdown in Canada.

OBJECTIVES: The closure of schools to prevent the spread of COVID-19 prompted concerns of deteriorating lifestyle behaviours, mental health, and wellbeing of children, particularly those in socioeconomically disadvantaged settings. We assessed changes in lifestyle behaviours (physical activity, screen time, eating habits and bed/wake-up times), mental health and wellbeing during the first lockdown in Spring 2020 as perceived by school children from disadvantaged settings, and examined determinants of these changes. STUDY DESIGN: Cross-sectional study. METHODS: We surveyed 1095 grade 4 to 6 students (age 9-12 years) from 20 schools in socioeconomically disadvantaged communities in northern Canada. Students reported on changes in lifestyle behaviours, mental health and wellbeing during the lockdown. Determinants of these perceived changes were examined in multivariable regression models. RESULTS: A majority of students reported declines in physical activity, having late bed/wake-up times, and modest improvements in mental health and wellbeing. Many students reported increases rather than decreases in screen time and snacking. Positive attitudes toward being active, eating healthy, going to sleep on time and being healthy were strongly associated with maintaining healthy lifestyle behaviours during the lockdown. Positive attitudes toward active and healthy living and healthy lifestyle behaviours were associated with maintaining positive mental health and wellbeing during the lockdown. CONCLUSIONS: The considerable changes in lifestyle behaviors, superimposed on the pre-existing burden of unhealthy lifestyle behaviours, put this generation of children at increased risk for future chronic disease. Findings call for effective health promotion of active and healthy lifestyles to benefit both physical and mental health.

Cost-effectiveness and return on investment of school-based health promotion programmes for chronic disease prevention.

BACKGROUND: While school-based health prevention programmes are effective in addressing unhealthy diet and physical inactivity, little is known about their economic implications. We conducted an economic evaluation of the programmes that were previously identified as feasible, acceptable, and sustainable in the Canadian context. METHODS: This study builds on a meta-analysis of the effectiveness of feasible, acceptable, and sustainable school-based health promotion programmes. A micro-simulation model incorporated intervention effects on multiple risk factors to estimate incremental cost-effectiveness and return on investment (ROI) of comprehensive school health (CSH), multicomponent, and physical education (PE) curriculum modification programmes. Cost-effectiveness was expressed as the programme costs below which the programme would be cost-effective at a CA$50 000 threshold level. RESULTS: The estimated costs below which interventions were cost-effective per quality-adjusted life year gained were CA$682, CA$444, and CA$416 per student for CSH, multicomponent, and PE curriculum modification programmes, respectively. CSH programmes remained cost-effective per year of chronic disease prevented for costs of up to CA$3384 per student, compared to CA$1911 and CA$1987 for multicomponent and PE curriculum modification interventions, respectively. If the interventions were implemented at total discounted intervention costs of CA$100 per student, ROI through the avoidance of direct healthcare costs related to the treatment and management of chronic diseases would be 824% for CSH, 465% for multicomponent interventions, and 484% for PE curriculum modification interventions. CONCLUSIONS: Whereas each examined intervention types showed favourable economic benefits, CSH programmes appeared to be the most cost-effective and to have the highest ROI.

A cross-sectional study examining convergent validity of a frailty index based on electronic medical records in a Canadian primary care program.

BACKGROUND: An electronic frailty index (eFI) has been developed and validated in the UK; it uses data from primary care electronic medical records (EMR) for effective frailty case-finding in primary care. This project examined the convergent validity of the eFI from Canadian primary care EMR data with a validated frailty index based on comprehensive geriatric assessment (FI-CGA), in order to understand its potential use in the Canadian context. METHODS: A cross-sectional validation study, using data from an integrated primary care research program for seniors living with frailty in Edmonton, AB. Eighty-five patients 65 years of age and older from six primary care physicians' practices were recruited. Patients were excluded if they were under 65 years of age, did not provide consent to participate in the program, or were living in a long term care facility at the time of enrolment. We used scatter plots to assess linearity and Pearson correlation coefficients to examine correlations. RESULTS: Results indicate a strong statistically significant correlation between the eFI and FI-CGA (r = 0.72, 95% CI 0.60-0.81, p < 0.001). A simple linear regression showed good ability of the eFI scores to predict FI-CGA scores (F (1,83) = 89.06, p < .0001, R2 = 0.51). Both indices were also correlated with age, number of chronic conditions and number of medications. CONCLUSIONS: The study findings support the convergent validity of the eFI, which further justifies implementation of a case-finding tool that uses routinely collected primary care data in the Canadian context.

Correction to: A cross-sectional study examining convergent validity of a frailty index based on electronic medical records in a Canadian primary care program.

Following the publication of this article [1], the authors reported a typesetting error in the "Results" section.

Application of an electronic Frailty Index in Australian primary care: data quality and feasibility assessment.

BACKGROUND: The primary care setting is the ideal location for identifying the condition of frailty in older adults. AIMS: The aim of this pragmatic study was twofold: (1) to identify data items to extract the data required for an electronic Frailty Index (eFI) from electronic health records (EHRs); and (2) test the ability of an eFI to accurately and feasibly identify frailty in older adults. METHODS: In a rural South Australian primary care clinic, we derived an eFI from routinely collected EHRs using methodology described by Clegg et al. We assessed feasibility and accuracy of the eFI, including complexities in data extraction. The reference standard for comparison was Fried's frailty phenotype. RESULTS: The mean (SD) age of participants was 80.2 (4.8) years, with 36 (60.0%) female (n = 60). Frailty prevalence was 21.7% by Fried's frailty phenotype, and 35.0% by eFI (scores > 0.21). When deriving the eFI, 85% of EHRs were perceived as easy or neutral difficulty to extract the required data from. Complexities in data extraction were present in EHRs of patients with multiple health problems and/or where the majority of data items were located other than on the patient's summary problem list. DISCUSSION: This study demonstrated that it is entirely feasible to extract an eFI from routinely collected Australian primary care data. We have outlined a process for extracting an eFI from EHRs without needing to modify existing infrastructure. Results from this study can inform the development of automated eFIs, including which data items to best access data from.

Improving Care Experiences, Efficiencies and Quality of Care for Seniors in Alberta.

Improving Care Experiences, Efficiencies and Quality of Care for Seniors in Alberta Forum was held to explore the current challenges and opportunities in seniors' care. A diverse group of 53 attendees, representing a cross section of healthcare organizations, front-line healthcare providers, researchers and patients, participated in facilitative, small group discussions to share and propose solutions to barriers to coordinating and integrating care for the senior population across the continuum within the Edmonton zone, to comment on a standardized assessment that may inform integrated care and support planning and to outline steps towards health information continuity.

"I just got tired of their healthy tips": health promotion during public health crises. / « J'ai fini par en avoir assez de leurs conseils santé ¼ : la promotion de la santé en période de crise de santé publique.

This qualitative study highlights parents' perspectives on pandemic-related changes to health promotion programming. We conducted 60-minute, semi-structured telephone interviews with 15 parents (all mothers) of children in Grades 4 to 6 between December 2020 and February 2021 in two western Canadian provinces. Transcripts were analyzed through thematic analysis. While some parents found the health promotion materials helpful, most were overwhelmed and did not access the materials, finding them intrusive, being preoccupied with other things and facing their own personal stressors. This study highlights key factors to be addressed and further investigated to ensure the successful delivery of health promotion programming during future crises.

Schools modified health promotion programming in response to the COVID-19 pandemic lockdowns and relied on parents to facilitate health promotion at home. Qualitative interviews with parents of children in Grades 4 to 6 revealed that parents were overwhelmed and often did not access health promotion materials. In the event of a future public health crisis, we identified strategies that can be used to increase parental engagement in facilitating health promotion at home.

Les écoles ont modifié leurs programmes de promotion de la santé à la suite des fermetures liées à la pandémie de COVID­19 et ont compté sur les parents pour faciliter la promotion de la santé à la maison. Les entrevues qualitatives réalisées avec des parents d'enfants de la 4e à la 6e année ont révélé que les parents étaient débordés et qu'ils ont été peu nombreux à consulter les documents de promotion de la santé. Nous avons cerné des stratégies aptes à favoriser la participation des parents à la promotion de la santé à la maison dans l'éventualité d'une nouvelle crise de santé publique.

The impact of the COVID-19 pandemic on inequalities in lifestyle behaviours and mental health and wellbeing of elementary school children in northern Canada.

Objectives: The COVID-19 pandemic has negatively affected children's lifestyle behaviours and mental health and wellbeing, and concerns have been raised that COVID-19 has also increased health inequalities. No study to date has quantified the impact of COVID-19 on health inequalities among children. We compared pre-pandemic vs. post-lockdown inequalities in lifestyle behaviours and mental health and wellbeing among children living in rural and remote northern communities. Methods: We surveyed 473 grade 4-6 students (9-12 years of age) from 11 schools in rural and remote communities in northern Canada in 2018 (pre-pandemic), and 443 grade 4-6 students from the same schools in 2020 (post-lockdown). The surveys included questions on sedentary behaviours, physical activity, dietary intake, and mental health and wellbeing. We measured inequality in these behaviors using the Gini coefficient, a unitless measure ranging from 0 to 1 with a higher value indicating greater inequality. We used temporal changes (2020 vs. 2018) in Gini coefficients to assess the impact of COVID-19 on inequalities in lifestyle behaviours and mental health and wellbeing separately among girls and boys. Results: Inequalities in all examined lifestyle behaviours increased between 2018 and 2020. Inequalities in watching TV, playing video games, and using a cell phone increased among girls, while inequalities in playing video games, using computers and tablets, and consumption of sugar, salt, saturated fat and total fat increased among boys. Changes in inequalities in mental health and wellbeing were small and not statistically significant. Conclusion: The findings suggest that the COVID-19 pandemic has exacerbated inequalities in lifestyle behaviours among children living in rural and remote northern communities. If not addressed, these differences may translate into exacerbated inequalities in future health. The findings further suggest that school health programs can help mitigate the negative impact of the pandemic on lifestyle behaviours and mental health and wellbeing.

Relationship Between Fruit and Vegetables Intake and Common Mental Disorders in Youth: A Systematic Review.

Objective: Recent evidence suggests that adequate fruit and vegetables intake (FVI) might be associated with lower risk of common mental disorders (CMDs) in adults, but studies in youth are also beginning to emerge and are synthesized in this systematic review. Methods: Online databases were searched from inception to 30 October 2020 to locate cross-sectional, cohort, and case-control studies focusing on the FVI and CMDs in youth (i.e., 10-18 years old). The risk of bias of studies was assessed using Joanna Briggs Institute Critical Appraisal Tool and the Newcastle-Ottawa quality assessment scale. Results: Among 3,944 records identified, 12 studies (8 cross-sectional, 1 case-control, and 3 prospective cohort studies) were included in the final synthesis. None of the prospective cohort studies identified a statistically significant association between FVI and CMDs in youth, although inconsistent associations were reported in cross-sectional and case-control studies. Conclusion: The lack of associations between FVI and CMDs in youth, along with consistent associations in adults, might be explained by the accumulation of risk theoretical model and methodological challenges.

From best practice to next practice: implementing Comprehensive School Health in rural and remote northern communities. / D'une pratique exemplaire à la pratique subséquente : mise en œuvre de l'Approche globale de la santé en milieu scolaire dans les collectivités rurales et éloignées du Nord.

INTRODUCTION: Northern communities in Canada experience a disproportionate burden of chronic diseases including mental illness. To mitigate the growing health inequalities, an ongoing Comprehensive School Health program promoting healthy lifestyle behaviours and mental health and well-being was expanded to rural and remote northern communities. We report on the program's impact on knowledge, attitudes, lifestyle behaviours (healthy eating, physical activity, screen time), weight status and the mental health and well-being of elementary school students during the first four years of implementation. METHODS: Following a repeated cross-sectional design, we surveyed 440, 352 and 384 Grade 4 to 6 students (9-12 years old) from eight schools in 2016, 2018 and 2020/21, respectively. Students were approximately equally represented by girls and boys. RESULTS: Between 2016 and 2018, students reported modest increases in vegetable and fruit consumption and dietary variety; declines in screen time; no changes in physical activity; and declines in attitudes toward healthy lifestyle and in mental health and well-being. Between 2018 and 2020/21, lifestyle behaviours deteriorated substantially, while attitudes and mental health and well-being continued to decline. CONCLUSION: A program that was successful in socioeconomically disadvantaged urban neighbourhoods had a favourable, though modest, impact on selected lifestyle behaviours, but not on attitudes and mental health and well-being, in rural and remote northern communities. In light of cultural differences and logistical challenges in Canada's North, systematic and proactive adaptations to local contexts, increased intensity, and longer program delivery are essential to facilitate sustainable improvements in lifestyle behaviours and mental health and well-being.

Mental Health and Wellbeing of 9-12-year-old Children in Northern Canada Before the COVID-19 Pandemic and After the First Lockdown.

Objectives: Children's mental health and wellbeing declined during the first COVID-19 lockdown (Spring 2020), particularly among those from disadvantaged settings. We compared mental health and wellbeing of school-aged children observed pre-pandemic in 2018 and after the first lockdown was lifted and schools reopened in Fall 2020. Methods: In 2018, we surveyed 476 grade 4-6 students (9-12 years old) from 11 schools in socioeconomically disadvantaged communities in Northern Canada that participate in a school-based health promotion program targeting healthy lifestyle behaviours and mental wellbeing. In November-December 2020, we surveyed 467 grade 4-6 students in the same schools. The 12 questions in the mental health and wellbeing domain were grouped based on correlation and examined using multivariable logistic regression. Results: There were no notable changes pre-pandemic vs. post-lockdown in responses to each of the 12 questions or any of the sub-groupings. Conclusion: Supporting schools to implement health promotion programs may help mitigate the impact of the pandemic on children's mental health and wellbeing. The findings align with recent calls for schools to remain open as long as possible during the pandemic response.

The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care.

(1) Background: Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot. (2) Methods: SCH was piloted in an academic clinic with six family physicians. Eligible patients were community dwelling, 65 years of age and older, and considered to be at risk of frailty (eFI > 0.12). Health professionals within the clinic received training in geriatrics and interprofessional teamwork to form the SCH team working with family physicians, patients and caregivers. The SCH intervention consisted of a team-based multi-domain assessment with person-centered care planning and follow-up. Patient-oriented outcomes (EQ-5D-5L and EQ-VAS) and 4-metre gait speed were measured at initial visit and 12 months later. (3) Results: 88 patients were enrolled in the pilot from April 2016-December 2018. No statistically significant differences in EQ-5D-5L/VAS or the 4-metre gait speed were detected in 38 patients completing the 12-month assessment. (4) Conclusions: Future larger scale studies of longer duration are needed to demonstrate impacts of integrated models of primary care on patient-oriented outcomes for older adults living with frailty.

"It's Very Stressful for Children": Elementary School-Aged Children's Psychological Wellbeing during COVID-19 in Canada.

Emerging evidence suggests that the COVID-19 pandemic and associated public health measures, including lockdowns and school closures, have been negatively affecting school-aged children's psychological wellbeing. To identify supports required to mitigate the negative impacts of the COVID-19 pandemic, we gathered in-depth information on school-aged children's and parents' lived experiences of COVID-19 and perceptions of its impact on psychological wellbeing in grade 4-6 students in Canada. In this qualitative study, we conducted telephone-based semi-structured interviews with parents (n = 15) and their children (n = 16) from six schools in small and mid-sized northern prairie communities in Canada. Interviews were analyzed through thematic analysis. Three interrelated themes have emerged. First, the start of COVID-19 brought sudden and stressful changes to children's lives. Second, disruptions to daily life led to feelings of boredom and lack of purpose. Third, limited opportunities for social interaction led to loneliness and an increase in screen time to seek social connection with peers. Results underscore the need for resilience building and the promotion of positive coping strategies to help school-aged children thrive in the event of future health crises or natural disasters.

Diet Quality and Health Service Utilization for Depression: A Prospective Investigation of Adults in Alberta's Tomorrow Project.

Depression is a leading cause of disability and economic burden worldwide. Primary prevention strategies are urgently needed. We examined the association of diet quality with depression in a large provincial cohort of adults. A past year food frequency questionnaire was completed by Alberta's Tomorrow Project (ATP) participants enrolled between 2000-2008 (n = 25,016; average age 50.4 years) and used to calculate Healthy Eating Index-Canada (HEI-C) 2015 scores. The number of physician visits for depression 2000-2015 was obtained via linkage with administrative health records. Negative binomial regression models assessed the relationship between HEI-C 2015 scores and physician visits for depression, adjusting for confounders. Every 10-unit increase in HEI-C 2015 scores was associated with 4.7% fewer physician visits for depression (rate ratio (RR): 0.95; 95% Confidence Interval (CI): 0.92-0.98). This relationship persisted when participants with physician visits for mental illness prior to cohort enrollment were excluded. Higher quality diets were associated with a lower number of physician visits for depression. Results highlight diet may be an important prevention strategy for reducing the burden of health service utilization for depression.

Co-consumption of Vegetables and Fruit, Whole Grains, and Fiber Reduces the Cancer Risk of Red and Processed Meat in a Large Prospective Cohort of Adults from Alberta's Tomorrow Project.

We examined whether co-consumption of red and processed meat with key foods items and food constituents recommended for cancer prevention (vegetables and fruit, whole grains, and fiber) mitigates cancer incidence. In a prospective cohort of 26,218 adults aged 35-69 years at baseline, dietary intake was collected through 124-item past-year food frequency questionnaire. Incidence of all-cause and 15 cancers previously linked to red and processed meat intake was obtained through data linkage with a cancer registry (average follow-up 13.5 years). Competing risk Cox Proportional Hazard models estimated cancer risk and Accelerated Failure Time models estimated time-to-cancer occurrence for different combinations of intake levels while considering mortality from vital statistics and established confounders. Co-consumption of low vegetables and fruit intake with high processed meat was associated with higher incidence of all-cause and 15 cancers (men: HR = 1.85, 1.91; women: HR = 1.44, 1.49) and accelerated time-to-cancer occurrence (men: 6.5 and 7.1 years and women: 5.6 and 6.3 years, respectively), compared to high vegetables and fruit with low processed meat intake. Less pronounced and less consistent associations were observed for whole grains and fiber and for red meat. The findings provide initial evidence toward refining existing cancer prevention recommendations to optimize the intake and combination of foods in the general adult population.

Effectiveness of school-based health promotion interventions prioritized by stakeholders from health and education sectors: A systematic review and meta-analysis.

Childhood obesity and associated modifiable risk factors exert significant burden on the health care system. The goal of this systematic review and meta-analysis was to examine the effectiveness of school-based intervention types perceived by Canadian stakeholders in health and education as feasible, acceptable and sustainable in terms of improving physical activity (PA), fruit and vegetable intake, and body weight. We searched multiple databases for studies that evaluated school-based interventions to prevent obesity and associated risk factors (i.e., unhealthy diet, physical inactivity, sedentary behaviour) in children aged 4-18 years from January 1, 2012 to January 28, 2020. From 10,871 identified records, we included 83 and 80 studies in our systematic review and meta-analysis, respectively. Comprehensive School Health (CSH) and interventions which focused on modifications to school nutrition policies showed statistically significant positive effects on fruit intake of 0.13 (95% CI: 0.04, 0.23) and 0.30 (95% CI: 0.1, 0.51) servings per day, respectively. No intervention types showed statistically significant effect on vegetable intake. CSH, modifications to physical education (PE) curriculum, and multicomponent interventions showed statistically significant difference in BMI of -0.26 (95% CI: -0.40, -0.12), -0.16 (95% CI: -0.3, -0.02), and -0.18 (95% CI: -0.29, -0.07), respectively. CSH interventions showed positive effect on step-count per day, but no other types of interventions showed significant effect on any of PA outcome measures. Thus, the results of this systematic review and meta-analysis suggest that decision-makers should carefully consider CSH, multicomponent interventions, modifications to PE curricula and school nutrition policies to prevent childhood obesity.