Characterizing Dietary Intakes in Rural Australian Adults: A Systematic Literature Review

Identifying the barriers and facilitators to fruit and vegetable consumption in rural Australian adults: a mixed methods analysis

BACKGROUND

Low fruit and vegetable consumption is a leading contributor to non-communicable disease risk. However, understanding of barriers and facilitators to fruit and vegetable intake in rural settings is limited. This study used a mixed methods approach to determine the barriers and facilitators to increasing fruit and vegetable intake in rural Australian adults and to identify if these varied by gender.

METHODS

Quantitative and qualitative data were used from the 2019 Active Living Census, completed by adults living in north-west Victoria, Australia. Data were collected on fruit and vegetable intakes and barriers and facilitators to meeting fruit and vegetable recommendations. Multivariate logistic regression analyses were used to investigate the association between facilitators, classified using the socio-ecological framework, and meeting recommendations. Machine learning was used to automate content analysis of open ended information on barriers.

RESULTS

A total of 13,464 adults were included in the quantitative analysis (51% female; mean age 48 [SE 0.17] years) with 48% and 19% of participants consuming the recommended two serves of fruit and five serves of vegetables daily, respectively. Strongest facilitators to fruit consumption were at the individual level: never smoked (OR: 2.12 95% CI: 1.83-2.45) and not drinking alcohol (OR: 1.47 95% CI: 1.31-1.64). Strongest facilitators for vegetable consumption were found at all levels; i.e., individual level: used to smoke (OR: 1.48 95% CI: 1.21-1.80), social-environmental level: living with three or more people (OR: 1.41 95% CI: 1.22-1.63), and physical-environmental level: use community gardens (OR: 1.20 95% CI: 1.07-1.34). Qualitative analyses (fruit n = 5,919; vegetable n = 9,601) showed that barriers to fruit consumption included a preference for other snacks and desire to limit sugar content, whilst lack of time and unachievable guidelines were barriers for vegetables. Barriers and facilitators differed by gender; females experienced barriers due to having a more varied diet while males reported a dislike of the taste.

CONCLUSIONS

Barriers and facilitators to fruit and vegetable consumption among rural Australian adults were identified across all levels of the socio-ecological framework and varied between fruit and vegetables and by gender. Strategies that address individual, social, and physical-level barriers are required to improve consumption.

Determining the feasibility of a codesigned and personalised intervention (Veg4Me) to improve vegetable intake in young adults living in rural Australian communities: protocol for a randomised controlled trial

INTRODUCTION

Diets low in vegetables are a main contributor to the health burden experienced by young adults in rural communities. Digital health interventions provide an accessible delivery model that can be personalised to meet the diverse preferences of young adults. A personalisable digital vegetable intake intervention (Veg4Me) was codesigned to meet the needs of young adults living in rural communities. This study will determine the feasibility of delivering a personalised Veg4Me programme and compare preliminary effects with a non-personalised Veg4Me (control).

METHODS AND ANALYSIS

A 12-week assessor-blinded, two-arm, parallel randomised controlled trial will be undertaken from August 2023 until April 2024. A total of 150 eligible and consenting young adults (18-35 years; eat<5 serves of vegetables/day; have an internet connected mobile device/computer) living in Loddon Campaspe or Colac Otway Shire in Victoria, Australia, will be randomised to receive 12 weeks of personalised (intervention) or non-personalised (control) support to increase vegetable intake via a free web application (app; Veg4Me). The primary outcome is feasibility (recruitment, participation and retention rates). Secondary outcomes are user engagement, usability and experience, as well as vegetable intake, eating habits and digital health equity. Process evaluation will be conducted in a subsample of participants using semistructured interviews. Descriptive statistics will be presented for the personalised and non-personalised groups at baseline and 12 weeks. Generalised linear models will be used to evaluate group differences in outcomes. Interviews will be transcribed and analysed thematically.

ETHICS AND DISSEMINATION

All procedures involving human subjects were approved by Deakin University's Human Ethics Advisory Group-Health (HEAG-H 06_2023) on 6 March 2023. Dissemination events will be held in the City of Greater Bendigo and the Colac Otway Shire. Summaries of the results will be disseminated to participants via email. Results will be disseminated to the scientific community through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry, ACTRN12623000179639p, prospectively registered on 21 February 2023, according to the World Health Organizational Trial Registration Data Set. Universal Trial Number U1111-1284-9027.

Co-design of a personalised digital intervention to improve vegetable intake in adults living in Australian rural communities

BACKGROUND

Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas. This paper describes the co-design of a digital intervention to improve vegetable intake with rural community members and research partners.

METHODS

Active participants in the co-design process were adults ≥ 18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population. Eight online workshops and a community survey were conducted between July and December 2021. The MoSCoW prioritisation method was used to help participants identify the 'Must-have, Should-have, Could-have, and Won't-have or will not have right now' features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community.

RESULTS

Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on (i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, (ii) access to personalisation options and behaviour change support, and (iii) improving the community food environment by providing information on and access to local food initiatives.

CONCLUSIONS

Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This research will inform the development of the prototyping (evaluation phase) and feasibility testing (post-design phase) of this intervention.

Development of a Scoring Tool for Australian Rural Food Retail Environments

Current tools scoring the healthiness of food retail outlets do not reflect outlets found in rural locations. This study aimed to adapt pre-existing Australian scoring tools to represent non-metropolitan areas. Rural nutrition experts were identified, and a modified Delphi technique was used to adapt two pre-existing, food-scoring tools in five iterative stages. Stages included identifying all relevant outlets, providing a description and score for each, ensuring consistency between outlet scores and pre-existing, metro-centric tools, and providing instructions for correct use. Six rural nutrition experts were identified and engaged in the modified Delphi technique. The final tool consisted of 12 categories of food outlets and listed 35 individual outlets. Consistent with pre-existing Australian tools, scores ranged from +10 to -10 and included descriptions reflective of rural retail outlets. Scores were based on whether the majority of foods offered within the outlet were consistent with foods recommended in national health guidelines. The developed tool was designed to accommodate the diverse nature of food retail outlets found in non-metropolitan areas. This study assists in explaining the link between the food environment and health in populations living rurally.

Rural nutrition and dietetics research-Future directions

AIM

The aim of this study was to summarise key evidence from recent Australian rural nutrition research and provide recommendations for future nutrition and dietetics research with rural communities.

CONTEXT

Clear evidence demonstrates that diet plays a role in the health gap between rural and metropolitan Australia. Despite the opportunity to address the health of rural Australians through better nutrition, alarmingly low investment in nutrition and dietetics research has occurred historically, and over the past decade.

APPROACH

A review of the evidence was undertaken by rural nutrition and dietetics leaders to provide a commentary piece to inform future rural nutrition research efforts.

CONCLUSION

Establishing strong, collaborative place-based nutrition and dietetics research teams are necessary to combat the significant gaps in the scientific knowledge of solutions to improve nutrition in rural Australia. Further, dieticians and nutritionists who live in and understand the rural contexts are yet to be fully harnessed in research, and better engaging with these professionals will have the best chance of successfully addressing the nutrition-related disease disparity between rural and metropolitan Australia.

HealthyRHearts - reducing cholesterol in rural adults via telehealth-based medical nutrition therapy: protocol for a cluster randomised controlled trial

BACKGROUND

Few randomised controlled trials specifically focus on prevention in rural populations. Cardiovascular disease (CVD) contributes to approximately one quarter of deaths in Australia. Nutrition is a key component affecting many risk factors associated with CVD, including hypercholesterolaemia. However, access to medical nutrition therapy (MNT) is limited for people living in rural areas, potentially exacerbating inequities related to health outcomes. Telehealth services present an opportunity to improve MNT access and address healthcare disparities for rural populations. The present study aims to evaluate feasibility, acceptability, and cost-effectiveness of a telehealth MNT CVD intervention program in lowering CVD risk over 12-months in regional and rural primary health care settings.

METHODS/DESIGN

A cluster randomised controlled trial set in rural and regional general practices in NSW, Australia, and their consenting patients (n = 300 participants). Practices will be randomised to either control (usual care from their General Practitioner (GP) + low level individualised dietetic feedback) or intervention groups (usual care from their GP + low level individualised dietetic feedback + telehealth MNT intervention). Telehealth consultations will be delivered by an Accredited Practising Dietitian (APD), with each intervention participant scheduled to receive five consultations over a 6-month period. System-generated generic personalised nutrition feedback reports are provided based on completion of the Australian Eating Survey - Heart version (AES-Heart), a food frequency questionnaire. Eligible participants must be assessed by their GP as at moderate (≥ 10%) to high (> 15%) risk of a CVD event within the next five years using the CVD Check calculator and reside in a regional or rural area within the Hunter New England Central Coast Primary Health Network (HNECC PHN) to be eligible for inclusion. Outcome measures are assessed at baseline, 3, 6 and 12 months. The primary outcome is reduction in total serum cholesterol. Evaluation of the intervention feasibility, acceptability and cost-effective will incorporate quantitative, economic and qualitative methodologies.

DISCUSSION

Research outcomes will provide knowledge on effectiveness of MNT provision in reducing serum cholesterol, and feasibility, acceptability, and cost-effectiveness of delivering MNT via telehealth to address CVD risk in rural regions. Results will inform translation to health policy and practice for improving access to clinical care in rural Australia.

TRIAL REGISTRATION

This trial is registered at anzctr.org.au under the acronym HealthyRHearts (Healthy Rural Hearts), registration number ACTRN12621001495819.

Dietary patterns in rural and metropolitan Australia: a cross-sectional study exploring dietary patterns, inflammation and association with cardiovascular disease risk factors

OBJECTIVES

This study sought first to empirically define dietary patterns and to apply the novel Dietary Inflammation Score (DIS) in data from rural and metropolitan populations in Australia, and second to investigate associations with cardiovascular disease (CVD) risk factors.

DESIGN

Cross-sectional study.

SETTING

Rural and metropolitan Australia.

PARTICIPANTS

Adults over the age of 18 years living in rural or metropolitan Australia who participated in the Australian Health survey.

PRIMARY OUTCOMES

A posteriori dietary patterns for participants separated into rural and metropolitan populations using principal component analysis.

SECONDARY OUTCOMES

association of each dietary pattern and DIS with CVD risk factors was explored using logistic regression.

RESULTS

The sample included 713 rural and 1185 metropolitan participants. The rural sample was significantly older (mean age 52.7 compared with 48.6 years) and had a higher prevalence of CVD risk factors. Two primary dietary patterns were derived from each population (four in total), and dietary patterns were different between the rural and metropolitan areas. None of the identified patterns were associated with CVD risk factors in metropolitan or rural areas, aside diet pattern 2 being strongly associated with from self-reported ischaemic heart disease (OR 13.90 95% CI 2.29 to 84.3) in rural areas. There were no significant differences between the DIS and CVD risk factors across the two populations, except for a higher DIS being associated with overweight/obesity in rural areas.

CONCLUSION

Exploration of dietary patterns between rural and metropolitan Australia shows differences between the two populations, possibly reflective of distinct cultures, socioeconomic factors, geography, food access and/or food environments in the different areas. Our study provides evidence that action targeting healthier dietary intakes needs to be tailored to rurality in the Australian context.

Understanding weight status and dietary intakes among Australian school children by remoteness: a cross-sectional study

OBJECTIVE

To determine whether primary school children's weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM).

DESIGN

A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake.

SETTING

Twelve regional and rural Local Government Areas in North-East Victoria, Australia.

PARTICIPANTS

Data were collected from 2456 grade 4 (approximately 9-10 years) and grade 6 (approximately 11-12 years) students.

RESULTS

The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)).

CONCLUSIONS

Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities.

Underinvestment in nutrition research for at-risk populations: An analysis of research funding awarded in Australia from 2014 to 2021

AIM

To determine the proportion of research projects funded by the National Health and Medical Research Council and Australian Research Council research funding from 2014 to 2021 that aimed to understand or improve dietary behaviours for at-risk populations in Australia and estimate the proportion of total funding allocated during this period.

METHODS

Retrospective analysis of the publicly available National Health and Medical Research Council and Australian Research Council funding grants over the 8 years from 2014 to 2021 (n = 18 098). At-risk dietary populations included people living in rural and remote Australia, Aboriginal and Torres Strait Islander people, or people living in socioeconomically disadvantaged areas. Descriptive analysis was undertaken.

RESULTS

In total, 144 out of 18 098 (0.8%) individual grants totalling $96.8 million were identified relating to nutrition research from 2014 to 2021. Out of the 144, only 21 ($19.6 million; 0.1%) of all National Health and Medical Research Council grants were identified for nutritionally at-risk populations, with the majority focused on Aboriginal and Torres Strait Islander people (15/21). The National Health and Medical Research Council and Australian Research Council grants that aimed to improve human dietary behaviours increased by 0.66% and 0.58%, respectively, from 2014 to 2021. However, the National Health and Medical Research Council grants aiming to improve nutritional behaviours in at-risk populations decreased by 0.04% over the 8 years.

CONCLUSIONS

Despite slight increases in the proportions of funding to improve dietary behaviours over the past decade, nutrition research specifically targeting at-risk groups is scarce and appears to have decreased over time. Insufficient investment in research for these groups presents a risk for widening health disparities now and into the future. As such, they must be further supported and considered in the design of future funding schemes.

The Impact of the COVID-19 Pandemic on Rural Food Security in High Income Countries: A Systematic Literature Review

Prior to the COVID-19 pandemic, rural-dwelling people in high-income countries were known to have greater challenges accessing healthy food than their urban counterparts. The COVID-19 pandemic has impacted food supplies across the world, and public health restrictions have changed the way people shop for food, potentially exacerbating food insecurity. This systematic literature review aimed to synthesize the available evidence on the impact of the COVID-19 pandemic on aspects of food insecurity in rural populations residing in high-income countries. Five electronic databases were searched, identifying 22 articles that assessed food insecurity prevalence or data on food availability, access, utilization and the stability of the food supply in rural populations during the COVID-19 pandemic. Ten studies examined the prevalence of food insecurity in rural populations, with the reported prevalence ranging from 15% to 95%. Where rural/urban comparisons were presented, most studies (n = 5; 71%) reported that food insecurity was significantly higher in rural regions. Five studies examined the availability of food and eight studies examined access to food, identifying that rural populations often had lower food availability and access to food during the pandemic. In contrast, two studies identified positive effects such as more gardening and increased online access to food. Rural populations experienced multiple changes to food utilization, such as reduced diet quality and food safety observed in eight studies, but this was not shown to be different from urban populations. Additionally, the food supply in rural regions was perceived to be affected in two studies. The results of this review may be used to inform region-specific mitigation strategies to decrease the impact of the current COVID-19 pandemic and future global events on food security. However, the lack of consistency in study outcomes in research on rural populations limits the identification of priority areas for intervention at a global-scale.

Characterizing the Health of Older Rural Australians Attending Rural Events: Implications for Future Health Promotion Opportunities

This paper describes the health of older Australians (>65 years) attending rural events to inform health promotion interventions for rural populations. This cross-sectional study collected survey data and objective health measures between 2017 and 2020 at two events held in rural New South Wales, Australia. Participants included in the analysis were adults > 65 years of age. Data included demographic and health information, anthropometric measures (height, weight, waist circumference), and dietary and physical activity data. A total of 256 people > 65 years participated. Our sample, which was mostly male (59.0%), contained people aged between 66 and 75 years (72.3%). Participants lived in either a large rural (34.0%) or small rural town (22.3%), with low levels of education (60.9% did not complete high school). Dietary quality was rated as below average. All but 17.2% of the participants reported having a health condition. The risk of a health condition was associated with increasing age, lower education, and higher waist circumference, but not remoteness. Rural events may provide an opportunity to access, engage with, and understand the health of older rural Australians, especially males. They may offer ideal contexts for health and nutrition promotion opportunities in rural areas where access to health professionals is limited.

A Comparison of Diet Quality in a Sample of Rural and Urban Australian Adults

The diet quality of rural Australians is under researched. Characterising disparities in diet quality between rural and urban populations may inform targeted interventions in at- risk groups. A cross-sectional study aimed to determine the relationship between diet quality, rurality and sociodemographic characteristics in a sample of Australian adults. Participants were recruited at rural and regional events between 2017 and 2020, in New South Wales, Australia. Diet quality was measured using the Healthy Eating Quiz or Australian Eating Survey to generate an Australian Recommended Food Score (ARFS). ARFS was compared by rurality and sociodemographic characteristics using multivariate regression. Participants (n = 247; 53% female) had a mean ± SD ARFS of 34.5 ± 9.0. There was no significant effect of rurality on ARFS (β-coefficient = −0.4; 95%CI −3.0, 2.3). Compared to participants aged 18–30 years, higher ARFS was evident for those aged 31–50 (β = 5.4; 95%CI 0.3, 10.4), 51–70 (β = 4.4; 95%CI 0.3, 8.5) and >71 years (β = 6.5; 95% CI 1.6–11.4). Compared to those living alone, participants living with a partner (β = 5.2; 95%CI 2.0, 8.4) and families with children (β = 5.6; 95%CI 1.4, 9.8) had significantly higher ARFS. ARFS was significantly lower with each additional self-reported chronic health condition (β = −1.4; 95%CI −2.3, −0.4). Our results indicate that diet quality as defined by the ARFS was classified as ‘getting there’ and that age, living arrangements and chronic health conditions, but not rurality, influenced diet quality in a sample of Australian adults.