Multisectoral partnerships to tackle complex health issues at the community level: lessons from a Healthy Communities Approach in rural Alberta, Canada.

SETTING: Health inequities exist in rural communities across Canada, as rural residents are more likely than their urban counterparts to experience injuries, chronic conditions, obesity, and shorter life expectancy. Cooperative and coordinated action across sectors is required to both understand and address these complex public health issues. INTERVENTION: The Alberta Healthy Communities Approach (AHCA) is based on the values and core building blocks of the Healthy Communities Approach, a framework centred on building community capacity to support community-led actions on the determinants of health. Adaptations within the AHCA focused on implementation mechanisms with a 5-step process and supporting implementation and assessment tools for multisectoral team building. Local measurement of change was enhanced and focused on community capacity and multisectoral action stages. Between 2016 and 2019, the AHCA was piloted with 15 rural communities across Alberta with population sizes ranging from 403 to 15,051 people. OUTCOMES: While communities piloting the AHCA ranged in the level of diversity of their coalition membership and partnerships, members' reflections demonstrate that intentional engagement with diverse citizens and sectors is pivotal to collaboratively identifying local assets and priorities and mobilizing cross-sectoral action that will sustainably improve supportive environments for cancer and chronic disease prevention. IMPLICATIONS: Engaging across sectors, building partnerships, and establishing a multisectoral team increase diversity and can catalyze community-led prioritization and actions for asset-based community development. An increase in diversity may lead to increased investment and sustainability at the community level.

RéSUMé: LIEU: Il existe des iniquités en santé dans les communautés rurales de tout le Canada, car les résidents ruraux sont plus susceptibles que leurs homologues urbains de connaître des blessures, des affections chroniques, l'obésité et une espérance de vie plus courte. Une action coopérative et coordonnée entre plusieurs secteurs est nécessaire à la fois pour comprendre ces problèmes de santé publique complexes et pour les aborder. INTERVENTION: L'approche des Communautés en santé de l'Alberta (AHCA) repose sur les valeurs et les composantes de base de l'approche des Communautés en santé, un cadre axé sur le renforcement des moyens de proximité pour soutenir des actions communautaires sur les déterminants de la santé. Les adaptations de l'AHCA ont porté sur les mécanismes de mise en œuvre de l'approche, dont un processus en cinq étapes et une aide à la création d'outils de mise en œuvre et d'évaluation pour la consolidation d'équipes multisectorielles. Les instruments de mesure du changement à l'échelle locale ont été améliorés et recentrés sur les moyens de proximité et les étapes de l'action multisectorielle. Entre 2016 et 2019, l'AHCA a été mise à l'essai dans 15 communautés rurales de l'Alberta comptant entre 403 et 15 051 habitants. RéSULTATS: Les communautés dans lesquelles l'AHCA a été mise à l'essai présentaient différents degrés de diversité dans les membres et les partenaires de leurs coalitions, mais les réflexions des membres montrent que la mobilisation intentionnelle d'une forte mixité de citoyens et de secteurs est cruciale pour définir de façon concertée les priorités et les atouts locaux et pour mobiliser une action intersectorielle qui instaure durablement des milieux favorables à la prévention du cancer et des maladies chroniques. CONSéQUENCES: L'implication de plusieurs secteurs, la création de partenariats et la formation d'une équipe multisectorielle accroissent la diversité et peuvent accélérer la définition des priorités collectives et les actions de développement de proximité fondées sur les atouts. Une augmentation de la diversité peut mener à des investissements et à une durabilité accrus à l'échelle des communautés.

Grain Products Are a Top Source of Energy and Nutrients among Nova Scotian Adults Following a Gluten-Free Diet.

To determine the food sources of energy and 13 core nutrients, 89 diet recalls were analyzed from an explanatory mixed-methods pilot study with adults following a gluten-free diet (GFD) for any reason. Nonconsecutive dietary recalls were collected through a web-based, Automated Self-Administered 24-Hour (ASA24®-Canada-2016) Tool. Mean nutrient intakes were compared with Dietary Reference Intakes. Food items (excluding supplements) were extracted and categorized according to the Bureau of Nutritional Sciences Food Group Codes. Percentages of total dietary intakes from food sources were ranked. Grain products were the highest ranked contributor of energy (21.4%), carbohydrate (30.3%), fibre (29.1%), and iron (35.3%). Breakfast cereals, hot cereals, yeast breads, and mixed grain dishes (mainly rice or pasta-based) were the most important nutrient contributors for grains, despite most (64.3%) commercial cereals and breads being unenriched. Legumes and seeds were not frequently consumed. Nutrient density in the GFD could be improved with more emphasis on gluten-free (GF) whole grains, legumes, seeds, and enriched breads and cereals. More research is needed on the nutrient composition of GF foods to identify food sources of folate, other B vitamins, zinc and magnesium-nutrients of concern for those requiring a GFD.

Adults following a gluten-free diet report little dietary guidance in a pilot survey exploring relationships between dietary knowledge, management, and adherence in Nova Scotia, Canada.

The strict nature of a gluten-free diet (GFD) poses a challenge for patient adherence and for clinicians to provide comprehensive client-centered care. Evidence on the relationship between nutrition knowledge, food skills, dietary management, and adherence can guide healthcare professionals counseling patients following this diet. In this explanatory pilot study, a province-wide survey (phase I) with 68 community-dwelling Nova Scotians following a GFD was conducted to investigate relationships between personal, social, and health care factors and dietary adherence using a mixed-methods approach. A sub-sample of 19 survey respondents were interviewed (phase II) to explore contextual experiences related to GFD knowledge, food skills, dietary management, and adherence using a food literacy lens. Here, we report findings from phase I, in which 37 participants with self-reported celiac disease (CD) and 31 participants reporting non-celiac reasons for wheat restriction (NCWR) completed a detailed 41-item online questionnaire. Self-reported data combined for both CD and NCWR respondents showed 76% perceived their health status as good to excellent. Most (62%) reported not receiving GFD advice from a health professional. Respondents with higher frequency of intentional consumption of gluten were more likely to have fewer correct answers to a food label quiz (ρ = -0.44; P = .0002). Most participants (75%) made at least one error in identifying gluten-free and gluten-containing foods, which may lead to unintentional gluten consumption and/or unnecessarily restricting safe foods. Findings from this exploratory study suggest patients may lack adequate referrals and support within the health care system and the community, adding to individual challenges of GFD adherence.

Canadian packaged gluten-free foods are less nutritious than their regular gluten-containing counterparts.

BACKGROUND: A strict gluten-free (GF) diet is required for the management of celiac disease (CD). The nutritional adequacy of this diet has been questioned due to the elimination of wheat, an important vehicle for micronutrient fortification and source of fibre. While novel and/or reformulated packaged GF products have rapidly entered the marketplace, providing alternatives to wheat-based staples, it is unknown whether these new products are nutritionally comparable. METHODS: From a database of 3,851 foods collected across 21 grocery stores in Eastern Canada, we compared the nutrient content of 398 unique GF items with 445 gluten-containing (GC) equivalents. Wilcoxon rank tests were conducted on listed nutrient content (g, mg, µg) per 100 g of product and the nutrient contribution of iron, folate and fibre were evaluated using Health Canada's nutrient claim regulations. RESULTS: GF staples (cereals, breads, flours, pastas) contained 1.3 times more fat and less iron (by 55%), folate (by 44%) and protein (by 36%), than GC counterparts (P < 0.0001). On average, GF pastas had only 37% of the fibre in GC pastas (P < 0.0001). Notably, GF and GC flours were equivalent in nutrient content. Despite GF and GC flours having similar nutritional content, the vast majority of the processed GF foods fell short in key nutrients. DISCUSSION: Packaged GF foods in Canada are generally less nutritious than their GC counterparts, suggesting that GF diets should not be promoted to those who do not require it. The use of nutrient-dense GF flours in homemade foods may improve nutrient intakes on the GF diet.

Gluten-Free Foods in Rural Maritime Provinces: Limited Availability, High Price, and Low Iron Content.

We investigated the price difference between gluten-free (GF) and gluten-containing (GC) foods available in rural Maritime stores. GF foods and comparable GC items were sampled through random visits to 21 grocery stores in nonurban areas of Nova Scotia, New Brunswick, and Prince Edward Island, Canada. Wilcoxon rank tests were conducted on price per 100 g of product, and on the price relative to iron content; 2226 GF foods (27.2% staple items, defined as breads, cereals, flours, and pastas) and 1625 GC foods were sampled, with an average ± SD of 66 ± 2.7 GF items per store in rural areas and 331 ± 12 in towns. The median price of GF items ($1.76/100 g) was more expensive than GC counterparts ($1.05/100 g) and iron density was approximately 50% less. GF staple foods were priced 5% higher in rural stores than in town stores. Although the variety of GF products available to consumers has improved, higher cost and lower nutrient density remain issues in nonurban Maritime regions. Dietitians working in nonurban areas should consider the relative high price, difficult access, and low iron density of key GF items, and work together with clients to find alternatives and enhance their food literacy.

A prospective evaluation of the depression-nutrient intake reverse causality hypothesis in a cohort of community-dwelling older Canadians.

Studies have investigated the potential protective effects that diet may have on late-life depression incidence. This disorder can, however, affect the person's food intake, widely known as the reverse causality hypothesis of depression. To test this hypothesis, we compared mean nutrient intakes from three 24-h recalls during the year depression was detected (Geriatric Depression Scale ≥11 or antidepressant medication) with intakes from 1 year earlier among community-dwelling older adults (67-83 years) followed up annually in the 4-year Québec Longitudinal Study on Nutrition and Aging, who were free of depression and cognitive impairment at baseline. Participants (n 158, 64·4 % female) who became depressed and had data available for all follow-up years were matched by age group and sex with non-depressed participants. General linear mixed models were adjusted for percentage changes in physical activity, functional autonomy and stressful life events reported at the time of positive screening. A significant group effect for the dietary intake of all three B-vitamins was observed, as depression cases had consistently lower dietary intakes than controls (P<0·01). Over time, intakes of dietary vitamin B12 declined within depressed participants in bivariate analysis, but there was no time×group effect for any nutrient tested in the multivariate analyses. Intakes of energy, protein, saturated fat and total dietary fibre did not change in cases v. CONTROLS: Among community-dwelling older adults, declines in dietary vitamins B6, B12 and folate may precede depression incidence. To help preventative efforts by programmes and practitioners, longitudinal cohorts of longer duration should investigate the extent of the decline in dietary intakes relative to the time of depression.

Dietary analysis of randomly selected meals from the Child Hunger and Education Program School Nutrition Program in Saskatchewan, Canada, suggests that nutrient target levels are being provided.

In Canada, school meals are regarded as important for social, educational, and nutritional reasons and have been provided for several years because of concerns about the health and welfare of children, especially those from low-income households. They are generally offered as local community organization and individual schools, are not regulated by law, and have no set national nutrition standards. The Canadian scientific literature lacks quantitative information on the nutritional adequacy of school meals. Better and more evaluation of such programs would encourage and guide administrators to assess other local programs in a similar fashion. Here, we describe the dietary assessment process of 1 school meal program in Canada and the nutritional adequacy of the meals. Throughout 10 years (1997-2007), the contents of 159 lunches and 90 breakfasts were collected mainly from elementary schools participating in the Child Hunger and Education Program Good Food, Inc's school nutrition program initiative in Saskatoon, Saskatchewan, Canada. We collected, weighed, and analyzed food samples from meals served to children at participating schools. We then compared their nutrient content against standards based on the Dietary Recommended Intakes for children aged 4 to 8 and 9 to 13 years using one third of the recommendations as the standard for lunches and one fourth for breakfasts. Overall, both meals had a good nutrient profile and met the standards for most analyzed macronutrients and micronutrients throughout the years. Although energy was persistently low, vitamin and mineral contents were often above the standards, reflecting a tendency to offer nutrient-dense foods in lieu of energy-dense foods. The rigorous methodology described in this manuscript can be followed to assess other small local programs. Furthermore, the dietary assessment presented can encourage not only the implementation of school meal programs in other locations but also the assessment of already existing programs-a clear need in the scientific literature.