Plain English Summary
Background and study aims
Recreation and sports facilities are community health promotion resources that have been found to have unhealthy food environments. The British Columbia, Alberta and Nova Scotia governments have introduced guidelines to improve food environments in these facilities. The aims of this study are to explore the impact of these guidelines on the food environments in these facilities across different provinces, and to test the impact of providing active support to facility management and staff. The study will also identify factors that influence implementation.
Who can participate?
Publicly funded municipal recreation and sport facilities
What does the study involve?
Facilities in provinces with nutrition guidelines are randomly allocated to either receive support or to not receive support. Support includes providing facility staff with a profile of their food environment, an online resource toolkit, seed grants, training, technical support and cross-site sharing. Staff at each facility look at their food environment profile, create a localized plan of action and implement these actions over 18 months. For instance they may create a new policy, working with their vending company or work with the concession provider to increase healthy food offerings. These facilities are compared with facilities in a province with no guidelines or support. Organizational capacity, policy development, vending and concession foods and environment, and patron purchasing patterns are compared at the start of the study and after 18 months.
What are the possible benefits and risks of participating?
Visitors and staff in the facilities may benefit because of the improved health profile of the food products provided. Facilities may become more aware of their food environment and adopt healthier policies and practices. Re-engineering food environments in publicly funded recreation and sport facilities is important to obesity prevention. The study findings will help to improve nutrition policies and support and may influence standard practice in recreation and sport facilities and other publicly funded institutions. As organizations are enrolled and not individuals there are no known risks to participation. However, loss of revenue is a typical perceived risk at the facility level.
Where is the study run from?
1. University of Victoria (Canada)
2. University of Alberta (Canada)
3. Dalhousie University (Canada)
4. University of Waterloo (Canada)
When is the study starting and how long is it expected to run for?
September 2015 to July 2018
Who is funding the study?
Heart and Stroke Foundation of Canada
Who is the main contact?
Dr Patti-Jean Naylor
Eat, Play, Live (EPL): a population intervention to promote nutrition guideline implementation in recreation facilities across three Canadian provinces
1. Recreation facilities in provinces that have developed nutrition guidelines for foods sold in municipal recreation will have significantly better facility capacity, policy development, vending and concession product health profiles and healthier patron purchasing patterns when compared with those in provinces without guidelines
2. Recreation facilities that receive additional support in the form of a capacity building intervention (CBI) will have significantly better facility capacity, policy development, vending and concession product health profiles and healthier patron purchasing patterns when compared to those that are exposed to guidelines only or that are not exposed to any guidelines
1. University of Victoria Human Research Ethics Board and University of British Columbia Behavioral Research Ethics Board, 07/28/2015, ref: BC15-196
2. University of Alberta Research Ethics Board 2, 8/21/2015, ref: Pro00058906
3. Dalhousie University Health Sciences Research Ethics Board, 10/05/2015, ref: 2015-3637
4. University of Waterloo Office of Research Ethics, 10/25/2015, ref: 20913
Multicentre interventional experimental design with randomization that uses a mixed-method concurrent triangulation design with quantitative and qualitative data analysis
Primary study design
Secondary study design
Randomised controlled trial
Patient information sheet
Not available in web format, please use the contact details to request a patient information sheet
This study evaluates the impact of two levels of intervention. The first level is provincial policy in the form of voluntary nutrition guidelines (including passive supports and resources released by government) and the second is provincial policy plus an 18-month CBI. Recreational facilities in provinces with nutrition guidelines will be randomized to either: guidelines plus CBI intervention (n = 18/6 per province BC, AB, NS), or guidelines only (with associated passive supports) comparison (n = 18/6 per province BC, AB, NS). A third comparison group (n = 18) will be randomly selected from a list of recreation facilities in a province that does not have nutrition guidelines for the recreation sector (Ontario).
Recreational facilities in provinces with nutrition guidelines will be randomized to one of two groups:
Group 1: Guidelines plus capacity building intervention (CBI). The CBI will link researchers, nutrition stakeholders and the development team (‘the resource group’) with recreation facility staff in each province (the ‘user group’). A provincial coordinator will act as the ‘linking agent/knowledge broker’ and provide training and technical support for communities as they assess their needs and create localized plans of action. The provincial coordinator will also link communities with the resources that are available to support their work: a toolkit -available in print or via a website (www.stayactiveeathealthy.ca), seed funding grants, suggested plans and processes for changing the recreation food environment and the information needed to take action (e.g. information about healthier food products, guidelines, ‘community stories/real world practices’, evaluation findings and templates for contracts, request for proposals, policies, etc.). Finally, the provincial coordinator will facilitate the knowledge to action cycle by providing rapid feedback of baseline results and ready access to published evaluations and evidence from practice-based research. In turn, lessons learned by the ‘user group’ will influence further actions within and across sites because of opportunities for cross-site sharing (e.g. teleconferences within and between jurisdictions).
Group 2: Guidelines only
Facilities in this arm of the trial are situated in provinces with voluntary provincial enacted but receive no active supports (although passive supports associated with the release and implementation guidelines or other initiatives are available through the internet if they are motivated to search for these).
Group 3: Comparison
This group has no provincial guideline or capacity-building efforts however they could access supports from other jurisdictions through the internet or other means.
Primary outcome measure
All of the following outcome measures will be assessed at baseline (Nov 2015-June 2016) and follow-up (Sept 2017-Feb 2018):
1. Facility Organizational Capacity is measured by an audit tool specifically designed for recreation facilities (a self-assessment of the current environment and level of capacity to address healthy eating within recreation facilities)
2. Policy Development is measured by the policy question on the above capacity audit tool along with a purpose built questionnaire that requests information about:
2.1. The status of facility level policy for the provision of healthy food
2.2. How provincial nutrition guidelines are addressed in the policy
2.3. The key food environment issues addressed in the policy
3. Food Environment - a reliable (test-retest and inter-rater reliability ≥ 0.88) four-step process will be used to audit the contents of two randomly selected snack and two randomly selected beverage vending machines per facility (Naylor et al, 2010). For each item present, a Research Assistant will record information on product brand, variety/type, size, flavour and price. This information will be used to calculate the proportion of products classified as: Sell Most (nutrient-dense; lower in sodium, sugar and fat), Sell Sometimes (source of essential nutrients; higher in sodium, sugar, and/or fat), and Do Not Sell (energy-dense and nutrient-poor; high in sodium, sugar, and/or fat) (BC Ministry of Health, 2014), using an online automated classification tool called the Brand Name Foodlist (https://bnfl.healthlinkbc.ca/) which uses BC’s food classification scheme to provide a consistent basis for cross-province comparisons
4. Food Environment - the concession food environment will be measured objectively using the Nutrition Environment Measures Survey–Restaurant (NEMS-R; fast casual version) (Lesser, Hunnes et al. 2012). The marketing questions will be enhanced with a valid and reliable checklist developed in Alberta that identifies food/beverage ad location (e.g. jerseys, scoreboards) and content (e.g. logos, appealing images) (Prowse et al 2018)
5. Patron Purchasing Patterns are measured using sales records for the products sold in vending machines and concession(s) will be collected for two weeks during baseline and follow-up
Secondary outcome measures
1. Meeting Minutes from Regional Teleconferences: During the 18-month intervention, meetings will be held quarterly with researchers, the Provincial Coordinator and representatives from CBI facilities; each will include a short verbal report from participating facilities that addresses activities to date, spin-off activities, issues and facilitators or barriers. Meeting minutes will be recorded and a facility events and activities list created
2. Facility Plans and 6 Month Reports: Each facility will submit their plan for activities they intend to complete along with a short report summarizing activities and events they actually did complete every 6 months. The research team will review these documents and summarize key activities on the facility events and activities list
3. Semi-Structured Interviews and Focus Groups with Recreation Administrators and Staff: These will explore elements of the context and CBI that facilitate and/or inhibit implementation. At each intervention facility, we will invite administrators (n = 18) and the staff identified by the administrator as ‘most involved’ in the nutrition policy change strategy to participate in individual semi-structured interviews. Interviews will be taped and transcribed verbatim
Overall trial start date
Overall trial end date
Reason abandoned (if study stopped)
Participant inclusion criteria
Publicly funded municipal recreation and sport facilities (not individuals) were eligible to participate if they: 1. Had not been involved in an intervention to improve their food environment since 2010
2. Offered food/beverages through vending machines and/or a concession
3. Had the ability to change their food environment
4. Offered recreational programming, preferably to children
Target number of participants
12 recreational facilities from each of the following Canadian provinces: British Columbia, Alberta and Nova Scotia, along with 18 recreational facilities from Ontario.
Total final enrolment
Participant exclusion criteria
Municipal recreation and sport facilities in each province that have recently taken action (within 5 years of study initiation) to change their facility food environment or participated in programs targeting change in the food environment
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
University of Victoria
School of Exercise Science, Physical and Health Education PO Box 3015 STN CSC
Trial participating centre
University of Alberta
4-077 Edmonton Clinic Health Academy 11405 – 87 Ave.
Trial participating centre
1318 Robie Street PO Box 15000
Trial participating centre
University of Waterloo
200 University Avenue
University of Victoria
3800 Finnerty Road
+1 (0)250 721 7211
Heart and Stroke Foundation of Canada
Heart and Stroke Foundation, Fondation des maladies du coeur et de l’avc, Fondation des Maladies du Cœur du Canada, HSFC, HSF
Funding Body Type
private sector organisation
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Provincial Advisory Committees will be formed in each guideline province to inform and support the research process. Committee meetings will be chaired by the study’s Provincial Coordinator, who will act as a ‘knowledge broker/linking agent’, linking the research team with the communities and recreation facilities in each province. Meetings held twice over the course of the study will provide a venue for dialogue among researchers, policy makers, health professionals (e.g. public health dietitian), industry (e.g. concession and vending machine company managers), and recreation professionals. In particular, we will solicit stakeholder views regarding the supports that are most important to provide, and that will be most beneficial to communities. Project data (process and outcome) will be presented as they become available to inform adjustments to capacity building activities; facilitating mobilizing knowledge to, and from, action (Graham, Logan et al. 2006). Sustainability and strategies to embed elements of the intervention within routine practice will be a key focus of the Committee’s ongoing discussions.
At the site level, knowledge translation and exchange are inherent within the CBI. Rather than relying on researchers to prescribe activities to improve each recreation facility’s food environment, research staff act as knowledge brokers/linking agents and instead support facilities in creating and executing their own facility-specific prioritized action plans by connecting them with evidence-informed practices. This will help to increase local buy-in to the project and will ensure that ultimate control remains with local communities. In addition, while some of the activities that will occur through this study have been pre-planned, others will be informed by input received from recreation facility managers, staff and patrons. The key knowledge exchange mechanism is ongoing discussions between the Provincial Coordinator and recreation facility staff and through facilitated cross-site knowledge exchange.
The trialists foresee conducting webinars and presenting to conferences of key stakeholders in addition to utilizing traditional academic dissemination vehicles (e.g. journals, academic conferences). They have budgeted for website (http://stayactiveeathealthy.ca/) and ‘newsletter’ style reports. The Provincial Advisory Committee will advise on the types of communication tools used to disseminate study findings to target audiences, such as policy briefings, fact sheets, press releases and webinars.
The trialists will submit a baseline cross-sectional analysis and methods paper and a longitudinal analysis paper for the main trial outcomes. They will also submit or have submitted papers on: tool development (marketing assessment and policy scoring tool), the impact of policy and localized contracts, implementation facilitators and barriers and the relationship between implementation levels and outcomes.
IPD sharing statement
The data sharing plans for the current study are unknown and will be made available at a later date.
Intention to publish date
Participant level data
To be made available at a later date
Basic results (scientific)
2019 results in: https://www.ncbi.nlm.nih.gov/pubmed/31238919 (added 18/07/2019)