A systematic review of observational studies exploring the relationship between health and non-weight-centric eating behaviours

Eating behaviour that does not centralise weight, otherwise known as weight-neutral, is associated with improved physical and psychological health, and greater health promoting behaviours. However, consolidated evidence is lacking. This study aimed to systematically evaluate 'health-centric' eating behaviour reflective of weight-neutral approaches, and their relationship with health (physical and mental) and health promoting behaviours. A systematic search was performed, identifying observational studies with adult populations, ≥1 physical/mental health outcome(s), and ≥1 validated measure(s) of health-centric eating behaviour. Study design, sample characteristics and outcomes were extracted and characterised into four domains. Our search identified 8281 records, with 86 studies, 75 unique datasets, and 78 unique exposures including 94,710 individuals. Eating behaviours included intuitive eating (n=48), mindful eating (n=19), and eating competence (n=11). There were 298 outcomes identified for body composition, size, and physical health (n=116), mental health and wellbeing (n=123), health promoting behaviours (n=51) and other eating behaviour (n=8). Higher levels of intuitive eating, mindful eating and eating competence were significantly related to a lower BMI, better diet quality and greater physical activity. Higher intuitive and mindful eating were significantly related to lower levels of disordered eating, and depressive symptoms, and higher body image, self-compassion, and mindfulness. Greater eating competence and intuitive eating were significantly related to higher fruit and vegetable intake, and greater eating competence to higher fibre intake and better sleep quality. Findings demonstrate that 'health-centric' eating behaviours are related to a range of favourable health outcomes and engagement in health promoting behaviours. Findings enhance the understanding of eating behaviours that do not centre around weight, providing support for health-centric eating behaviour in healthcare. Future research should focus on intervention studies and more diverse population groups.

Describing the food choices of Aboriginal children attending an afterschool cultural program from two different knowledge systems: The importance of Country, community, and kinship

AIMS

This study describes a program co-created with Aboriginal communities to strengthen cultural ties with the children. Food data are reported from two knowledge systems (lenses): Western and Aboriginal relational, focused on Country, community, and kinship.

METHODS

A cultural program was undertaken with primary school children of Aboriginal heritage, on Yuin nation, over 10 weeks including culturally appropriate practices (painting, bushtucker, and dance). We report mixed method food outcomes framed by Western (quantitative) 24-h recall and Aboriginal relational methods (qualitative) captured by cultural images, yarning and continuous consultation methods to expose lessons from community and Country, to extend kinship.

RESULTS

In total, 111 children (79 providing food data) across three regional communities commenced the program. A storying approach to food data collection and interpretation was preferred. The number of serves of seafood products, such as fish increased, vegetable consumption improved, intakes of dairy improved in quality and energy intakes from discretionary foods decreased across the programs. Qualitative data exposed six themes: Eating with family, competing agendas, food as medicine, applying cultural practices, food choices driven by 'post-invasion tradition' and community events, which deepened our understanding of the food data. Teaching the importance of the ocean and water saw participants engage with family in practices such as fishing to improve overall awareness of culture through food.

CONCLUSION

The kinship system in a cultural context supported positive shifts towards accessible food choices driven by messages from Country. While the changes cannot be isolated to the program, cultural immersion drove change and strength-based reporting.

The role of multidisciplinary MS care teams in supporting lifestyle behaviour changes to optimise brain health among people living with MS: A qualitative exploration of clinician perspectives

INTRODUCTION

Healthcare professionals have an important role in advocating for the adoption of a brain-healthy lifestyle for optimal multiple sclerosis (MS) care. Nonetheless, studies to date have mainly focussed on the consumer perspective. Herein, we aimed to explore the current practices of how healthcare professionals support protective, lifestyle-related behaviour changes to optimise brain health among people living with MS (plwMS), and their perspectives of professional roles.

METHODS

Australian healthcare professionals were recruited via study advertisements, purposive and snowball sampling, to participate in an online, semi-structured and audio-recorded interview. Clinicians were eligible if they had a minimum of a tertiary Bachelor's degree and 12-months experience working with plwMS, access to the Internet and sufficient time to participant. An inductive, data-driven form of reflexive thematic analysis was undertaken before thematic categorisation of the quotes from transcripts. Data analysis was guided by the methods of Braun and Clark and the study's underpinnings drew on the constructs of the Social Cognitive Theory (SCT).

RESULTS

Six physicians, 10 MS nurses, 18 allied health professionals, one exercise therapist and one alternative therapist were interviewed. Three primary themes encompassing the perceived role of healthcare professionals in supporting a brain-healthy lifestyle were identified: (1) the empowering role, (2) collaborative role and (3) communicative role. External factors/forces including time constraints, professional expertise, training and skill set, power dynamics, consumer readiness, health literacy, self-efficacy and motivation are at play, and affect how/when healthcare professionals may support behaviour change to optimise lifelong brain health for plwMS.

CONCLUSION

Healthcare professionals recognise their critical role in encouraging and supporting the adoption of a brain-healthy lifestyle to optimise lifelong brain health for plwMS. However, discord is evident when they underestimate the complexity of translating knowledge of lifestyle-related behaviour change(s) into action. Greater awareness must be made in recognising and addressing the bidirectionality of external factors such as those in the SCT, that may influence how behaviour change occurs.

PUBLIC CONTRIBUTION

Healthcare professionals volunteered to be interviewed as part of the data collection phase of this study.

Relationships are essential but not always easy: The role of methodology in embedding Aboriginal community and Country in academic research

This article is told as a story about how a project, Strong culture, healthier lifestyles, took steps towards decolonisation as an evolving methodological journey with Country. The story is primarily about how our methodology moved from a Western model of 'doing' research, to the research team being part of the research process, as team members with Country and the participating local community members: a methodology of partnership. First, we provide a general overview of the initial project to set up how we came to understand its disconnection to community and Country. Second, we unpack the storying approach as methodology that is bound with the local Country: Yuin on the South Coast of New South Wales, Australia. Third, using the storying approach, we reflect through Country and the community to discover ways forward in Aboriginal and non-Aboriginal knowledge partnerships. We share our story in an attempt to limit colonial practice (decolonisation) and replace it with a re-culturalising approach; the re-connecting of Country as a source of interconnectedness into the research process. Country includes all the living communities of nature, and we explore how this relationship in the human element (community) impacted and developed our methodology of partnership.

The relationship between internalised weight bias and biopsychosocial outcomes in children and youth: a systematic review

OBJECTIVE

To synthesise the evidence on the relationships between internalised weight bias (IWB) and biopsychosocial health outcomes in individuals ≤ 25 years.

METHODS

A systematic review was conducted by searching five scientific databases up to May 2022 to retrieve studies that investigated associations between IWB and biopsychosocial outcomes. Articles with participants ≤ 25 years, at least one validated measure of IWB, one measure of a biopsychosocial outcome, and were observational were included. Excluded articles involved systematic literature reviews, case study reports, intervention studies, meta-analyses, grey literature, pilot, and feasibility studies. Quality assessment was carried out using the American Dietetic Association Quality Criteria Checklist. The protocol was registered with PROSPERO, ID number CRD42022323876.

RESULTS

Two hundred and sixty-six articles were identified. Nineteen were eligible for inclusion, (15 cross-sectional and 4 prospective). The Weight Bias Internalization Scale and the Weight Self-Stigma Questionnaire were the most used tools to assess IWB with large heterogeneity in tool types used to assess biopsychosocial measures. IWB had positive associations with psychopathology, eating disorder symptomology, higher BMI, being female, and experiences of weight stigma. It was negatively associated with quality of life, body image, physical activity, social ability, self-esteem, and socioeconomic status.

DISCUSSION

IWB associated with adverse biopsychosocial outcomes in children and youth populations. IWB may be more clinically relevant in assessing at-risk children and youth than physical weight due to its psychosocial aspects and ability to expand beyond the scope of BMI. Research would benefit from better assessment tools designed for children and youth that accurately measure IWB. Future research should focus on increased diversity and longitudinal study designs with children and youth-specific populations.

Strong culture, healthy lifestyles: a mixed methods feasibility study for a co-created afterschool cultural programme for Australian Aboriginal children

BACKGROUND

Having a strong connection to culture and Country is fundamental to the health and wellbeing of Australian Aboriginal children. The aim of the research was to evaluate the feasibility of study methods and programme implementation of a co-created afterschool cultural programme, and identify areas for improvement.

METHODS

Aboriginal Relational Research Methodology and mixed methods were applied to evaluate the feasibility of the implementation of the programme and study methods using a non-randomised single-group study design. Australian Aboriginal children and their siblings aged 5-13 years were recruited within regional New South Wales, Australia. The primary outcomes for feasibility included recruitment rates of children and Aboriginal programme mentors, compliance rates of outcome data collection and of the planned programme activities, programme attendance, retention rates and mean enjoyment scores. Follow-up yarning circles were conducted with the children, their parents/caregivers, programme mentors and teachers to explore aspects of feasibility, and areas for improvement.

RESULTS

A total of 90 caregivers consented to their children (n = 111) being part of the research. Sixteen Aboriginal mentors were recruited to deliver the programmes across the communities. Overall, 74.4% of all health outcome measures were completed across baseline (86.5%) and follow-up (55.9%). Only 61.0% of the programme activities were delivered as originally planned. The average programme attendance rate was 70.0% with a 92.0% retention rate. Eighty-nine percent of children reported a high level of enjoyment with the programmes. Follow-up yarning identified the importance of relational methodologies and flexibility within the programme design and implementation to ensure programmes were adapted to the local community, conditions and differing age groups. Considerations for future programmes included the timing of the programme and identifying health outcome assessment tools and methods that acknowledge cultural protocols and experiences.

CONCLUSIONS

Engaging the communities in the development, implementation and evaluation of the programmes were key to community support of the programme and conducting the feasibility study. Future programmes and evaluations need to be built on strong partnerships and embrace flexible and culturally embedded methodologies in order to be adaptive and responsive to research approaches, communities and to Country.

TRIAL REGISTRATION

ACTRN12619001224112. Retrospectively registered on 05 September 2019.

The effect of oral synbiotics on the gut microbiota and inflammatory biomarkers in healthy adults: a systematic review and meta-analysis

CONTEXT

Prior research has explored the effect of synbiotics, the combination of probiotics and prebiotics, on the gut microbiota in clinical populations. However, evidence related to the effect of synbiotics on the gut microbiota in healthy adults has not been reviewed to date.

OBJECTIVE

A systematic review and meta-analysis was conducted to comprehensively investigate the effect of synbiotics on the gut microbiota and inflammatory markers in populations of healthy adults.

DATA SOURCES

Scopus, PubMed, Web of Science, ScienceDirect, MEDLINE, CINAHL, and The Cochrane Library were systematically searched to retrieve randomized controlled trials examining the primary outcome of gut microbiota or intestinal permeability changes after synbiotic consumption in healthy adults. Secondary outcomes of interest were short-chain fatty acids, inflammatory biomarkers, and gut microbiota diversity.

DATA EXTRACTION

Weighted (WMD) or standardized mean difference (SMD) outcome data were pooled in restricted maximum likelihood models using random effects. Twenty-seven articles reporting on 26 studies met the eligibility criteria (n = 1319).

DATA ANALYSIS

Meta-analyses of 16 studies showed synbiotics resulted in a significant increase in Lactobacillus cell count (SMD, 0.74; 95% confidence interval [CI], 0.15, 1.33; P = 0.01) and propionate concentration (SMD, 0.22; 95% CI, 0.02, 0.43; P = 0.03) compared with controls. A trend for an increase in Bifidobacterium relative abundance (WMD, 0.97; 95% CI, 0.42, 2.52; P = 0.10) and cell count (SMD, 0.82; 95% CI, 0.13, 1.88; P = 0.06) was seen. No significant differences in α-diversity, acetate, butyrate, zonulin, IL-6, CRP, or endotoxins were observed.

CONCLUSION

This review demonstrates that synbiotics modulate the gut microbiota by increasing Lactobacillus and propionate across various healthy adult populations, and may result in increased Bifidobacterium. Significant variations in synbiotic type, dose, and duration should be considered as limitations when applying findings to clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO no. CRD42021284033.

Exploring factors to interpretation of targeted nutrition messages for people living with multiple sclerosis

OBJECTIVES

Current dietary recommendations for MS suggest following national dietary guidelines developed for the general population. The aim of this study was to explore the interpretation of MS-targeted nutrition messages.

METHODS

Using the Elaboration Likelihood Model of persuasion, three nutrition messages were developed targeting the strongest evidence for MS: vitamin D, dietary fat, and dietary diversity. Semi-structured interviews including the cognitive 'thinking-aloud' technique were used to test the messages with adults living with MS. Data were transcribed and coded thematically.

RESULTS

Theoretical saturation was reached by 15 interviews. The data corpus indicated three themes and seven subthemes. The data revealed that people living with MS changed their diet after MS diagnosis. Dietary change was due to uncertainty, fear of disease progression and risk of relapse. The admiration and scepticism of extremist MS diets depended on personal vulnerability and support from health care professionals. The unique MS journey appeared influential to message interpretation; driven by engagement, practicality, and credibility.

CONCLUSION

The interpretation of targeted nutrition messages revealed that dietary changes made after diagnosis are a coping mechanism to improve sense of control and self-management.

PRACTICAL IMPLICATIONS

The potential psychological benefit of dietary change for MS management must be prioritised using person-centred care.

Avocado intake and cardiometabolic risk factors in a representative survey of Australians: a secondary analysis of the 2011-2012 national nutrition and physical activity survey

BACKGROUND

Avocados are a rich source of nutrients including monounsaturated fats, dietary fibre and phytochemicals. Higher dietary quality is reported in studies of consumers with higher avocado intakes. The present study aimed to examine avocado consumption and cardiometabolic risk measures in a representative sample of Australian adults.

METHODS

A cross-sectional analysis was performed using Australian Health Survey 2011-2013 (n = 2,736 observations). Day 1 24-hour recall data was used to examine reported avocado intake (whole avocados and avocado-containing products excluding avocado oil) and cardiometabolic risk measures (LDL, HDL, and total cholesterol, triglycerides, apolipoprotein B, HbA1c, plasma glucose, systolic and diastolic blood pressure). T-tests and chi square analyses were conducted between low (5.21 [95% CI: 4.63, 5.79] grams/day) and high (44.11 [95% CI: 35.89, 52.33] grams/day) consumers of avocado.

RESULTS

14.7% of Australians were 'avocado consumers' (n = 403 observations). Mean avocado intake was 24.63 (95% CI: 20.11, 29.15) grams per day, with a median intake of 10.40 (IQR: 4.49-26.00) grams per day for those considered 'avocado consumers'. Consumers of avocados had a lower BMI and waist circumference (each, p ≤ 0.001), lower plasma glucose level (p = 0.03), and higher HDL cholesterol (p ≤ 0.001) when compared with non-consumers. A trend towards lower plasma glucose, HbA1c (each, p = 0.04) and higher dietary fibre intake (p = 0.05) was found between high and low consumers of avocado.

CONCLUSIONS

Our study suggests favourable outcomes for avocado intake and cardiometabolic characteristics of consumers. Future studies should explore glucose homeostasis using a clinical trial design to understand potential relationships between avocado intake and cardiometabolic risk factors.

Towards new perspectives: A scoping review and meta-synthesis to redefine brain health for multiple sclerosis

BACKGROUND AND PURPOSE

Research promoting the health of the brain has increased exponentially over the last decade. The importance of 'brain health' for multiple sclerosis (MS), as one example, is a high priority. However, as research into the concept increases, so does varied use of the term.

METHODS

A scoping review, guided by the methodological framework of the Joanna Briggs Institute, was conducted to collate the evidence relating to brain health for MS. A comprehensive literature search incorporated six search strategies to retrieve both scientific and grey literature sources. All evidence sources were qualitatively charted and synthesized (meta-synthesis) according to their definition of brain health used, outcome measures and brain-healthy lifestyle elements.

RESULTS

Seventy evidence sources (34 peer reviewed, 36 grey literature) were eligible for inclusion. Of these, just over half (n = 40, 57%) provided a definition of brain health. The most common definition alluded to the biomedical model of neurological reserve (n = 22, 55%), a self-remodelling theory described to retain optimal brain function. Twenty-nine outcome measures of brain health were identified, the most frequent being magnetic resonance imaging metrics (n = 25, 83%). Physical activity was the most prevalent brain-healthy lifestyle element (n = 44), followed by avoidance of smoking (n = 26) and diet (n = 24).

CONCLUSIONS

Brain health should be considered a primary target for optimal disease and lifestyle management across the MS disease course. A working definition reflecting a shift from a medical lens towards broader biopsychosocial contexts that may influence brain health for people living with MS is proposed.

Exploring the socio-ecological factors impacting lifestyle management of multiple sclerosis: A scoping review

BACKGROUND

Multiple sclerosis (MS) is a chronic, autoimmune, neurodegenerative disorder affecting over 2.9 million people worldwide. First line care revolves around disease modifying therapy and supporting people living with MS to manage their disease. Early management often sees lifestyle modification as people living with MS try to gain a sense of control. Lifestyle management is an evolving area of care with variable strength of evidence for different lifestyle factors.

OBJECTIVE

To explore factors that impact on the self-management of MS with a socio-ecological focus.

METHODS

A scoping review following the Joanna Briggs Institute guidelines for a systematic search was conducted across six databases with 9241 articles identified and 51 included in the review. The results were analysed in conjunction with the socio-ecological model considering the categories: individual, interpersonal, organisational, community, and public policy.

RESULTS

A map of health behaviour (lifestyle) factors extending across all levels of the socio-ecological model revealed a complex web of pathways to behavioural patterns impacting MS self-management. Factors followed a cascading effect towards either of two key principles: (1) self-identity or (2) accessibility. These principles in-turn impact on an individual's self-efficacy, and hence, effectiveness of MS self-management strategies.

CONCLUSIONS

MS care is highly individualised to the personal context and circumstances of the individual, with consideration towards suitable management strategies required. Healthcare professionals must consider these lifestyle influences and coordinate an approach to assisting people living with MS to self-manage their disease in relation to their personal circumstances. Person-centred care addressing both barriers and motivators to health behaviour changes is key to effective MS self-management.

Lifestyle Interventions, Kidney Disease Progression, and Quality of Life: A Systematic Review and Meta-analysis

Rationale & Objective

Poor dietary patterns and low physical activity levels are important lifestyle-related factors that contribute to negative health outcomes in individuals with chronic kidney disease (CKD). Previous systematic reviews have not explicitly focused on these lifestyle factors, nor undertaken meta-analyses of any effects. We aimed to evaluate the effect of lifestyle interventions (such as diet, exercise, and other lifestyle-related interventions) on the risk factors for and progression of CKD and the quality of life.

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

Individuals aged 16 years or older with CKD stages 1 to 5 not requiring kidney replacement therapy.

Selection Criteria for Studies

Randomized controlled trials of interventions.

Data Extraction

Kidney function, albuminuria, creatinine, systolic blood pressure, diastolic blood pressure, body weight, glucose control, and quality of life.

Analytical Approach

A random-effects meta-analysis with evidence certainty assessed using GRADE.

Results

Seventy-eight records describing 68 studies were included. Twenty-four studies (35%) were dietary interventions, 23 (34%) exercise, 9 (13%) behavioral, 1 (2%) hydration, and 11 (16%) multiple component. Lifestyle interventions resulted in significant improvements in creatinine (weighted mean difference [WMD], -0.43 mg/dL; 95% CI, -0.74 to -0.11; P = 0.008); 24-hour albuminuria (WMD, -53 mg/24 h; 95% CI, -56 to -50; P < 0.001); systolic blood pressure (WMD, -4.5 mm Hg; 95% CI, -6.7 to -2.4; P < 0.001); diastolic blood pressure (WMD, -2.2 mm Hg; 95% CI, -3.7 to -0.8; P = 0.003); and body weight (WMD, -1.1 kg; 95% CI, -2.0 to -0.1; P = 0.025). Lifestyle interventions did not result in significant changes in the estimated glomerular filtration rate (0.9 mL/min/1.73 m²; 95% CI, -0.6 to 2.3; P = 0.251). However, narrative synthesis indicated that lifestyle intervention resulted in improvements in the quality of life.

Limitations

Certainty of the evidence was rated very low for most outcomes, primarily owing to the risk of bias and inconsistency. No meta-analysis was possible for quality-of-life outcomes because of variations in measurement tools.

Conclusions

Lifestyle interventions seem to positively affect some risk factors for progression of CKD and quality of life.

Medical and nursing clinician perspectives on the usability of the hospital electronic medical record: A qualitative analysis

BACKGROUND

Electronic medical records (EMRs) have been widely implemented in Australian hospitals. Their usability and design to support clinicians to effectively deliver and document care is essential, as is their impact on clinical workflow, safety and quality, communication, and collaboration across health systems. Perceptions of, and data about, usability of EMRs implemented in Australian hospitals are key to successful adoption.

OBJECTIVE

To explore perspectives of medical and nursing clinicians on EMR usability utilising free-text data collected in a survey.

METHOD

Qualitative analysis of one free-text optional question included in a web-based survey. Respondents included medical and nursing/midwifery professionals in Australian hospitals (85 doctors and 27 nurses), who commented on the usability of the main EMR used.

RESULTS

Themes identified related to the status of EMR implementation, system design, human factors, safety and risk, system response time, and stability, alerts, and supporting the collaboration between healthcare sectors. Positive factors included ability to view information from any location; ease of medication documentation; and capacity to access diagnostic test results. Usability concerns included lack of intuitiveness; complexity; difficulties communicating with primary and other care sectors; and time taken to perform clinical tasks.

CONCLUSION

If the benefits of EMRs are to be realised, there are good reasons to address the usability challenges identified by clinicians. Easy solutions that could improve the usability experience of hospital-based clinicians include resolving sign-on issues, use of templates, and more intelligent alerts and warnings to avoid errors.

IMPLICATIONS

These essential improvements to the usability of the EMR, which are the foundation of the digital health system, will enable hospital clinicians to deliver safer and more effective health care.

Higher diet quality is associated with short and long-term benefits on SF-6D health state utilities: a 5-year cohort study in an international sample of people with multiple sclerosis

BACKGROUND/PURPOSE

Health state utilities (HSU) are a subjective measure of an individual's health-related quality of life (HRQoL), adjusted by societal or patient relative preference weights for living in different states of health-related quality of life (HRQoL), derived from patient-reported responses to multi-attribute utility instrument (MAUI), and can be used as inputs for cost-utility analyses and in clinical assessment. This research assessed associations of diet with subsequent HSU in a large international cohort of people living with multiple sclerosis (MS), a progressive autoimmune condition of the central nervous system.

METHODS

HSUs were generated from responses to Short-Form Six-Dimension (SF-6D) MAUI, and quality-of-the-diet by Diet Habits Questionnaire (DHQ). Cross-sectional, and short- and long-term prospective associations of DHQ with HSU evaluated by linear regression at 2.5- and 5-years. Pooled prospective associations between DHQ and HSU evaluated using linear and quantile regression. Analyses adjusted for relevant demographic and clinical covariates.

RESULTS

Among 839 participants, baseline DHQ scores showed short- and long-term associations with subsequent HSU, each 10-unit increase in total DHQ score associated with 0.008-0.012 higher HSU (out of 1.00). These associations were dose-dependent, those in the top two quartiles of baseline DHQ scores having 0.01-0.03 higher HSU at follow-up, 0.03 being the threshold for a minimally clinically important difference. Fat, fiber, and fruit/vegetable DHQ subscores were most strongly and consistently associated with better HSU outcomes. However, baseline meat and dairy consumption were associated with 0.01-0.02 lower HSU at subsequent follow-up.

CONCLUSIONS

A higher quality-of-the-diet showed robust prospective relationships with higher HSUs 2.5- and 5-years later, substantiating previous cross-sectional relationships in this cohort. Subject to replication, these results suggest interventions to improve the quality-of-the-diet may be effective to improve HRQoL in people living with MS.

Higher consumption of ultra-processed foods and increased likelihood of central nervous system demyelination in a case-control study of Australian adults

BACKGROUND

Consumption of ultra-processed foods (UPFs) has been linked to risk of chronic diseases, with scant evidence in relation to multiple sclerosis (MS).

METHODS

We tested associations between UPF consumption and likelihood of a first clinical diagnosis of central nervous system demyelination (FCD) (267 cases, 508 controls), a common precursor to MS. We used data from the 2003-2006 Ausimmune Study and logistic regression with full propensity score matching for age, sex, region of residence, education, smoking history, body mass index, physical activity, history of infectious mononucleosis, dietary misreporting, and total energy intake.

RESULTS

Higher UPF consumption was statistically significantly associated with an increased likelihood of FCD (adjusted odds ratio = 1.08; 95% confidence interval = 1.0,1.15; p = 0.039), representing an 8% increase in likelihood of FCD per one energy-adjusted serving/day of UPFs.

CONCLUSION

Higher intakes of UPF were associated with increased likelihood of FCD in this Australian cohort. Nutrition education and awareness of healthy eating patterns may benefit those at high risk of FCD.

Insights from dietitians providing individualised dietetic care to people living with disabilities: A single site exploration in the community

BACKGROUND

The present study aims to share insights and lessons learnt by dietitians providing individualised care to people living with disabilities in the community. This is important to build the evidence to inform dietetic best practice standards.

METHODS

The study involved a cross-sectional data audit of dietitian reports for clients living with a disability seen at a metropolitan dietitian clinic in South Australia. Content analysis of the reports was conducted. Initial coding occurred deductively followed by inductive qualitative content analysis.

RESULTS

Thirty-one participants consented to have their dietitian reports included in the study. Intellectual disabilities made up the majority (48%) of disabilities reported in the sample. Nutrition diagnoses predominantly related to energy imbalances (54%). Barriers to dietary change included a reliance on others and limitations in the disability support system. Kitchen skills and cooking were the most often employed nutrition strategy suggested by dietitians. Following dietetic intervention, improvements were seen in the types of foods people with a disability consumed along with changes to their body weight. Dietitians reported the importance of effective communication with the care team and providing engaging methods to instigate dietary behaviour change.

CONCLUSIONS

The present study highlights that there are opportunities to build on individualised dietetic care provided to people living with disabilities. These opportunities include addressing excess energy consumption, fostering collaborations with other health providers and understanding how to better work with carers. Further research is required to understand how to progress these opportunities forward and to understand the generalisability of the findings.

Evaluating augmented reality for 'real life' teaching of food portion concepts

BACKGROUND

Estimation of food portions is a vital skill for dietitians, which is developed during formal nutrition training. Skill development is often accomplished by training with food portion estimation tools. These tools can vary in design but evaluations often reveal them to be limited in their effectiveness and generally impractical for everyday use. The aim of this study was to develop and evaluate an augmented reality (AR) tool for the estimation food portions.

METHODS

An online, quasi-experimental, randomised pre-test post-test study was conducted to evaluate the effectiveness of three food portion tools with nutrition students. These tools consisted of an online, AR, and an infographic tool (control). Students tested 10 different food images and were asked to estimate food portion sizes with and without assistance of a portion tool to determine absolute error, relative error, and overall improvement in estimation.

RESULTS

A total of 33 participants enrolled in the study with 26 (72.0%) completing the study. The mean absolute error was lowest in the online group (53.0%), followed by AR (59.5%) and control (64.0%). Relative error scores revealed higher accuracy for the AR group (45.5%) followed by online (43.5%), and control group (29.0%). Overall improvement in estimation was highest in the AR group (+12.2%) followed by the online (+11.6%) tool with a decrease seen for the infographic (-1.7%) tool.

CONCLUSIONS

The use of technology, notably AR technology, may provide some advantage when training nutrition students in food portion estimation, although further investigation is advised.

Using Online 24-h Dietary Methodology to Validate the Psychometric Properties of a Dietary Scoring Tool with an International Sample of Adults Living with Multiple Sclerosis

Understanding the dietary characteristics of people living with multiple sclerosis (plwMS) may assist in the planning of nutrition interventions for multiple sclerosis; yet dietary assessment methods in existing studies are not well established. The aim of this study was to validate the psychometric properties (construct validity and internal consistency) of the Dietary Habits Questionnaire (DHQ) against repeated online 24-h recall dietary assessments. The DHQ is a 24-item tool that is scored using ten dietary sub-scores. Total DHQ scores can range from 20−100 and are considered indicative of the quality of dietary intake with higher scores reflecting increased quality. People living with a relapsing-remitting MS phenotype who had completed a modified DHQ were recruited from the international Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) cohort. Repeated 24-h recall via the online Automated Self-administered Assessment-24 (ASA-24) tool were modelled to reflect usual dietary intakes using the Multiple Source Method. DHQ scores of eight sub-scores: three key nutrients, three food groups and two food preparation practices, were calculated and statistically compared with ASA-24 usual intake data. Principal component analysis of the ASA-24 data was undertaken to understand dietary patterns of the sample. Of the 105 participants, valid 24-h recall data were available for 96 plwMS (n = 66 1 day, n = 30 ≥ 2 day). The median total DHQ score was 84.50 (IQR: 77.04, 91.83) points. The highest absolute correlations were between the DHQ scores and ASA-24 data for cereal (r = 0.395, p < 0.001), fruit and vegetables (r = 0.436, p < 0.001), and total dietary fiber (r = 0.482, p < 0.001). Five dietary patterns emerged from the data explaining 42.12% variance and reflecting exposure of plwMS to the influence of ‘MS diets’. The DHQ appears to be appropriate for screening participants with relapsing-remitting MS. Evidence-based dietary models focusing on food are required to monitor the quality of an overall dietary pattern and set priorities for the planning nutrition interventions for plwMS.

Estimated Choline Intakes and Dietary Sources of Choline in Pregnant Australian Women

(1) Background: Despite the postulated importance of choline during pregnancy, little is known about the choline intake of Australians during pregnancy. In this study, we estimated dietary intakes of choline in early and late pregnancy, compared those intakes to recommendations, and investigated food sources of choline in a group of pregnant women in Australia. (2) Methods: 103 pregnant women enrolled in a randomized controlled trial. In early pregnancy (12−16 weeks gestation) and late pregnancy (36 weeks gestation), women completed a food frequency questionnaire designed to assess dietary intake over the previous month. (3) Results: Choline intakes and sources were similar in early and late pregnancy. Median choline intake in early pregnancy was 362 mg/day. Of the women, 39% and 25% had choline intakes above the Australian National Health and Medical Research Council (NHMRC) adequate intake (AI) of >440 mg/day and the European Food Safety Authority (EFSA) AI of >480 mg/day for choline in pregnancy, respectively. Eggs, red meat, nuts, legumes, and dairy accounted for 50% of choline intake, with eggs being the most significant contributor at 17%. (4) Conclusions: Few pregnant women in our study met the AI recommended by the NHMRC and EFSA. In Australia, choline intake in pregnancy may need to be improved, but further work to define choline requirements in pregnancy is required.

Total Dairy Consumption Is Not Associated With Likelihood of a First Clinical Diagnosis of Central Nervous System Demyelination

Background

The evidence associating consumption of dairy products and risk of MS is contradictory and inconclusive.

Objective

To test associations between dairy consumption and the likelihood of a first clinical diagnosis of central nervous system demyelination (FCD), a common precursor to MS.

Methods

We used data from the 2003–2006 Ausimmune Study, a population-based Australian, multicentre, matched case-control study (272 cases, 519 controls). Total dairy consumption (servings/day) was calculated by summing consumption of milk, cheese and yogurt. Covariate-adjusted treatment effects using augmented inverse probability weighting was used to test for associations with FCD. We conducted sensitivity analyses in the subset of participants who had had a classic first demyelinating event (FDE), defined as a single, first episode of symptoms suggestive of CNS demyelination.

Results

There were no statistically significant associations between total dairy consumption (per one serving/day) and FCD (adjusted OR 1.00; 95% CI 0.93, 1.07; p = 0.979). However, yogurt consumption (vs. no yogurt consumption) was associated with an 11% decreased likelihood of FDE (adjusted OR 0.89; 95% CI 0.89, 0.79; p = 0.046).

Conclusion

While total dairy consumption was not associated with FCD in this Australian case-control study, yogurt consumption was associated with reduced likelihood of FDE.

Patient self-management and empowerment for multiple sclerosis: The implications of dietary lifestyle management for primary care

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological condition of increasing prevalence. Many people living with MS will trial various alternative therapies, including changed patterns of eating, to try to gain control over their condition. New clinical guidelines advise reducing the time between first clinical symptoms and treatment. It is the support of the healthcare team that can empower the person in their healthcare journey.

OBJECTIVE

The aim of this article is to provide insights into the role of diet as an element of lifestyle management of MS and describe the implications of diet as a first-line treatment for MS.

DISCUSSION

Many 'MS diets' have been promoted to persons diagnosed with MS, yet evidence-based advice is necessitated by an expressed need. Although health risks of short-term exploration of specific diets are not likely to cause concern, lifestyle management should be included in communication plans, with referrals to other healthcare professionals as appropriate.

Global Perspective of the Vitamin D Status of African-Caribbean Populations: A Systematic Review and Meta-analysis

BACKGROUND/OBJECTIVES

Vitamin D deficiency remains a global public health issue, particularly in minority ethnic groups. This review investigates the vitamin D status (as measured by 25(OH)D and dietary intake) of the African-Caribbean population globally.

SUBJECTS/METHODS

A systematic review was conducted by searching key databases (PUBMED, Web of Science, Scopus) from inception until October 2019. Search terms included 'Vitamin D status' and 'African-Caribbean'. A random effects and fixed effects meta-analysis was performed by combining means and standard error of the mean.

RESULT

The search yielded 19 papers that included n = 5670 African-Caribbean participants from six countries. A meta-analysis found this population to have sufficient (>50 nmol/L) 25(OH)D levels at 67.8 nmol/L, 95% CI (57.9, 7.6) but poor dietary intake of vitamin D at only 3.0 µg/day, 95% CI (1.67,4.31). For those living at low latitudes 'insufficient' (as defined by study authors) 25(OH)D levels were found only in participants with type 2 diabetes and in those undergoing haemodialysis. Suboptimal dietary vitamin D intake (according to the UK recommended nutrient intake of 10 µg/day) was reported in all studies at high latitudes. Studies at lower latitudes, with lower recommended dietary intakes (Caribbean recommended dietary intake: 2.5 µg/day) found 'sufficient' intake in two out of three studies.

CONCLUSIONS

25(OH)D sufficiency was found in African-Caribbean populations at lower latitudes. However, at higher latitudes, 25(OH)D deficiency and low dietary vitamin D intake was prevalent.

Dietary patterns and associations with health outcomes in Australian people with multiple sclerosis

BACKGROUND/OBJECTIVES

Associations between patterns of food intake and health in people with multiple sclerosis (MS) are of increasing global interest; however, Australian data are lacking. This study aimed to assess the dietary habits and associations with health outcomes of Australians with MS.

SUBJECTS/METHODS

This cross-sectional study used 2016 survey data from the Australian MS Longitudinal Study, including the Dietary Habits Questionnaire, Hospital Anxiety and Depression Scale, Assessment of Quality of Life, Fatigue Severity Scale, Patient-Determined Disease Steps Scale and 13 MS symptoms scales. Regression models were constructed using directed acyclic graphs.

RESULTS

Almost all (94.3%) of the 1490 participants reported making an effort to eating healthy with 21.2% following one or more specific diets, although often not strictly. Overall, 7.9% reported not eating meat, 8.1% reported not consuming dairy, and 4.0% consumed neither food group. A healthier diet score was associated with better mental, physical and total quality of life, and lower depression, and pain scores, and fewer cognition, vision and bowel symptoms. Higher reported fibre, fruit, vegetable and healthy fat scores were positively associated with most health outcomes.

CONCLUSIONS

Healthier overall diet scores and higher fibre, fruit and vegetable scores were associated with better health outcomes in this sample of Australians adults with MS. However, the proportion of participants avoiding dairy and meat, or adhering to a specific MS diet was much lower than previously reported. Prospective dietary studies are needed to further understand whether dietary change is feasible and affects health outcomes over time.

Clinical researchers' lived experiences with data quality monitoring in clinical trials: a qualitative study

BACKGROUND

Fundamental to the success of clinical research that involves human participants is the quality of the data that is generated. To ensure data quality, clinical trials must comply with the Good Clinical Practice guideline which recommends data monitoring. To date, the guideline is broad, requires technology for enforcement, follows strict industry standards, mostly designed for drug-registration trials and based on informal consensus. It is also unknown what challenges clinical trials and researchers face in implementing data monitoring procedures. Thus, this study aimed to describe researcher experiences with data quality monitoring in clinical trials.

METHODS

We conducted semi-structured telephone interviews following a guided-phenomenological approach. Participants were recruited from the Australian and New Zealand Clinical Trials Registry and were researchers affiliated with a listed clinical study. Each transcript was analysed with inductive thematic analysis before thematic categorisation of themes from all transcripts. Primary, secondary and subthemes were categorised according to the emerging relationships.

RESULTS

Data saturation were reached after interviewing seven participants. Five primary themes, two secondary themes and 21 subthemes in relation to data quality monitoring emerged from the data. The five primary themes included: education and training, ways of working, working with technology, working with data, and working within regulatory requirements. The primary theme 'education and training' influenced the other four primary themes. While 'working with technology' influenced the 'way of working'. All other themes had reciprocal relationships. There was no relationship reported between 'working within regulatory requirements' and 'working with technology'. The researchers experienced challenges in meeting regulatory requirements, using technology and fostering working relationships for data quality monitoring.

CONCLUSION

Clinical trials implemented a variety of data quality monitoring procedures tailored to their situation and study context. Standardised frameworks that are accessible to all types of clinical trials are needed with an emphasis on education and training.

A National Survey of EMR Usability: Comparisons between medical and nursing professions in the hospital and primary care sectors in Australia and Finland

BACKGROUND

Electronic Medical Record Systems (EMRs) are now part of nursing and medical professionals daily work in the acute and primary care sectors in Australia. Usability is an important factor in their successful adoption and impacts upon clinical workflow, safety and quality, communication, and collaboration. This study replicates a significant body of work conducted by Finnish researchers applying a usability focused survey to understand medical and nursing professionals' experiences in the Australian context. As we implement EMRs across health systems, their usability and design to support clinicians to effectively deliver and document care, is essential.

METHODS

We conducted an observational study using a cross sectional survey, the National Usability-Focused HIS Scale (NuHISS) developed and validated by Finnish researchers. For this study 13 usability statements collected clinician impressions of EMRs related to technical quality, ease of use, benefits, and collaboration. We report the responses from medical and nursing professionals working in clinical practice settings in Australia, including primary care and hospital sectors in 2020.

RESULTS

Nursing and medical professionals have different experiences with EMR usability. This depends on the sector they work in and the usability feature measured. In our sample, technical quality features were more positively experienced by doctors in the primary care sector than nurses as well as ease of obtaining patient information and prevention of errors. In the hospital sector nurses experiences with EMRs were more positive with respect to support for routine task completion, learnability, ease of obtaining patient information and entry of patient data.

CONCLUSIONS

The NuHISS is a suitable tool for measuring the usability experiences of Australian clinicians and the EMRs utilised. Differences in usability experiences were noted between professional groups and sectors. A focus on the usability perspectives of clinicians when enhancing or developing EMR solutions is advocated.

Higher-quality diet and non-consumption of meat are associated with less self-determined disability progression in people with multiple sclerosis: A longitudinal cohort study

Background and purpose

Modifiable lifestyle factors, including diet, may affect clinical outcomes in multiple sclerosis (MS). This study assessed the relationships between diet, and disability, fatigue, and depression risk in people with MS.

Methods

Participants from the Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) international cohort were assessed over 2.5 years. Dietary data were obtained using a modified Diet Habits Questionnaire (DHQ), disability using the calculated Patient‐determined MS Severity Score (P‐MSSS), fatigue using the Fatigue Severity Scale, and depression risk using the Patient Health Questionnaire‐2. Participants reported whether they were experiencing symptoms due to a recent relapse. Cross‐sectional and prospective relationships of diet and disease outcomes were explored, adjusted for relevant confounders.

Results

Among 1,346 participants, higher DHQ scores showed significant dose‐dependent associations with lower frequencies of severe disability, fatigue, and depression risk, cross‐sectionally. Prospectively, higher baseline DHQ scores were associated with a lower risk of increasing disability, those above the median having 41% and 36% lower risk of increasing disability, and 0.30 P‐MSSS points less disability progression, but were not associated with fatigue or depression risk. Meat consumption was associated with 0.22 P‐MSSS points higher disability cross‐sectionally, while prospectively, baseline meat consumption was associated with 76% higher risk of increasing disability and 0.18 P‐MSSS points higher disability progression. Dairy consumption showed mixed associations cross‐sectionally and prospectively.

Conclusions

These results show that better quality of diet, as well as not consuming meat, were associated with reduced disability progression in people with MS. Substantiation of these findings in other settings may inform opportunities to manage disability progression in people with MS using dietary modifications.

A Clinician-Led, Experience-Based Co-Design Approach for Developing mHealth Services to Support the Patient Self-management of Chronic Conditions: Development Study and Design Case

BACKGROUND

Despite the increasing use of mobile health (mHealth) services, such as mHealth apps or SMS text messaging services, that support the patient self-management of chronic conditions, many existing mHealth services lack theoretical guidance. In addition, although often the target audience for requirement acquisition at the initial mHealth app design stage, it is a common challenge for them to fully conceptualize their needs for mHealth services that help self-manage chronic conditions.

OBJECTIVE

This study proposes a novel co-design approach with the initial requirements for mHealth services proposed by clinicians based on their experiences in guiding patients to self-manage chronic conditions. A design case is presented to illustrate our innovative approach to designing an mHealth app that supports the self-management of patients with obesity in their preparation for elective surgery.

METHODS

We adopted a clinician-led co-design approach. The co-design approach consisted of the following four cyclic phases: understanding user needs, identifying an applicable underlying theory, integrating the theory into the prototype design, and evaluating and refining the prototype mHealth services with patients. Expert panel discussions, a literature review, intervention mapping, and patient focus group discussions were conducted in these four phases.

RESULTS

In stage 1, the expert panel proposed the following three common user needs: motivational, educational, and supportive needs. In stage 2, the team selected the Social Cognitive Theory to guide the app design. In stage 3, the team designed and developed the key functions of the mHealth app, including automatic push notifications; web-based resources; goal setting and monitoring; and interactive health-related exchanges that encourage physical activity, healthy eating, psychological preparation, and a positive outlook for elective surgery. Push notifications were designed in response to a patient's risk level, as informed by the person's response to a baseline health survey. In stage 4, the prototype mHealth app was used to capture further requirements from patients in the two focus group discussions. Focus group participants affirmed the potential benefits of the app and suggested more requirements for the function, presentation, and personalization needs. The app was improved based on these suggestions.

CONCLUSIONS

This study reports an innovative co-design approach that was used to leverage the clinical experiences of clinicians to produce the initial prototype app and the approach taken to allow patients to effectively voice their needs and expectations for the mHealth app in a focus group discussion. This approach can be generalized to the design of any mHealth service that aims to support the patient self-management of chronic conditions.

Time-consuming and expensive data quality monitoring procedures persist in clinical trials: A national survey

INTRODUCTION

The Good Clinical Practice guideline identifies that data monitoring is an essential research activity. However, limited evidence exists on how to perform monitoring including the amount or frequency that is needed to ensure data quality. This study aims to explore the monitoring procedures that are implemented to ensure data quality in Australian clinical research studies.

MATERIAL AND METHODS

Clinical studies listed on the Australian and New Zealand Clinical Trials Registry were invited to participate in a national cross-sectional, mixed-mode, multi-contact (postal letter and e-mail) web-based survey. Information was gathered about the types of data quality monitoring procedures being implemented.

RESULTS

Of the 3689 clinical studies contacted, 589 (16.0%) responded, of which 441 (77.4%) completed the survey. Over half (55%) of the studies applied source data verification (SDV) compared to risk-based targeted and triggered monitoring (10-11%). Conducting 100% on-site monitoring was most common for those who implemented the traditional approach. Respondents who did not conduct 100% monitoring, included 1-25% of data points for SDV, centralized or on-site monitoring. The incidence of adverse events and protocol deviations were the most likely factors to trigger a site visit for risk-based triggered (63% and 44%) and centralized monitoring (48% and 44%), respectively.

CONCLUSION

Instead of using more optimal risk-based approaches, small single-site clinical studies are conducting traditional monitoring procedures which are time consuming and expensive. Formal guidelines need to be improved and provided to all researchers for 'new' risk-based monitoring approaches.

A meta-synthesis of competency standards suggest allied health are not preparing for a digital health future

OBJECTIVE

This study reviewed the competency and threshold standards for allied health professionals to identify the inclusion of digital health competencies.

MATERIALS AND METHODS

A nine-stage, sequential meta-synthesis of professional standards was undertaken. Statements relevant to digital health were extracted, categorised by discipline, and coded to the level in the standards, skills or knowledge and level of learning.

RESULTS

Eighteen standards were analysed. Of these, fourteen standards contained a total of thirty-five statements related to digital health in the themes of data governance and technologies, but not data translation. Only four disciplines included more than two statements related to digital health.

DISCUSSION

The study highlighted four key gaps in the Standards. Statements in competency and threshold standards for allied health professionals lack reference to digital health, with predominantly information management statements. The statements are ambiguously worded, and could be interpreted to only refer to paper records management, and when there is a reference to digital health, it is more likely to be a skill as opposed to knowledge, typically at the indicator or cue level, and largely a lower level of learning (Bloom's). The lack of digital health in standards may result in limited instruction in already full tertiary education curriculum.

CONCLUSION

Digital health represents a major gap in competency statements for all allied health disciplines, signifying the need for a national approach to developing quality and specific digital health competencies, to support allied health graduates being prepared to work in the digital health age.

Validated liquid chromatography separation methods for identification and quantification of anthocyanins in fruit and vegetables: A systematic review

Food composition data are challenged by data availability and quality. Anthocyanins are the bright colored pigments found in fruits and vegetables with growing evidence for health benefits. For the estimation of anthocyanin content in the foods, it is imperative to find an ideal analytical method. To quantify anthocyanin components, liquid chromatography-based methods are commonly used. This review addresses the variability of liquid chromatography (LC) mass spectrometry (MS) methods for the identification and quantification of anthocyanins. Published studies for all years until February 2020 reporting LC methods for anthocyanins in fruits and vegetables were screened from 7660 studies. Only 29 studies met the eligibility criteria of method type and of these, only 13 studies reported a validated LC method. A wide range of validation parameters were identified including specificity, calibration, stability, and limits of detection. Differences in the sampling amounts for extraction were observed in all of the included studies. The quantification of multiple anthocyanin types without their corresponding analytical standards was observed in eight studies. The included 13 studies used reverse phase liquid chromatography separation with C₁₈ type or similar stationary phases and acidified aqueous or acidified aqueous: organic (usually methanol or acetonitrile) binary gradient mobile phases. Although all of the studies used mass spectrometry for identification, ultraviolet absorbance quantification was often used in conjunction with a photo-diode array (DAD/PDA) detector using reference standards where available. Extraction and preparation of samples remains the key concern for analysis as the oxidative stability of anthocyanins are a major impediment for accurate quantification of the components in foods. This review provides a summary of validated LC methods to assist analysts and nutritionists in the quantification of anthocyanin food components as the nutrient profiles of foods are challenged by the variability of the analytical methods.

Healthy eating and physical activity environments in out-of-school hours care: an observational study protocol

INTRODUCTION

Childcare settings have been widely identified as important venues for promoting healthy lifestyles to children. Out-of-school hours care (OSHC) is a rapidly growing childcare service, yet there has been limited research reported on healthy eating and physical activity (HEPA) environments within the Australian OSHC setting. This research aims to describe the HEPA environments related to foods and beverages served, staff behaviours and child physical activity levels across two local health districts within New South Wales, Australia. This study will provide evidence to support future interventions and policies in Australian OSHC settings.

METHODS AND ANALYSIS

A cross-sectional study design will be used to describe the food and beverages provided and child activity levels, and report on environmental correlates. OSHC programmes will be visited on non-consecutive weekdays between 2018 and 2020. The frequency of foods and beverages offered will be observed and categorised into food groups aligned to the Australian Dietary Guidelines. Children's physical activity will be measured using ActiGraph wGT3X-BT accelerometers. Staff behaviour will be captured via direct observation and the System for Observing Staff Promotion of Activity and Nutrition. Short interviews with programme directors will gather contextual information about OSHC practices and policies.

ETHICS AND DISSEMINATION

Findings will be disseminated through peer-reviewed scientific journals, conference presentations and individualised feedback to each participating service. Ethical approval was granted by the University of Wollongong Human Research Ethics Committee (HE17/490).

Exploring dietary changes in an interdisciplinary intervention trial: Application of a dietary guidelines food composition database

BACKGROUND

Consumption of food groups aligning with dietary guidelines is advised for obesity management and was used in a recent lifestyle intervention trial, the Health Track study. We have conducted a number of dietary pattern analyses on this trial but, with recent access to the new Australian Dietary Guidelines (ADG) food composition database, we can now assess ADG adherence, with the advantage of categorising mixed dishes. The present study aimed to compare changes over time in consumption of ADG food groups.

METHODS

Secondary analysis of baseline and three-month diet history data was conducted. Participants received individualised dietary advice (I), individualised dietary advice plus 30 g of walnuts per day (IW) or usual care (C). The ADG database was used to determine food group servings with changes in five food groups used as a measure of dietary quality.

RESULTS

Fruit and vegetable intakes increased in the IW (+0.4 and +1.1 serves, P < 0.05) and I (+0.5 and +0.4 serves, P > 0.05) arms. Consumption of meat/protein foods increased in the IW arm (+0.3 serves, P > 0.05) but decreased in the I and C arms (both - 0.4 serves, P < 0.05). Consumption of grains and milk/alternatives decreased in all study arms (P < 0.05). Greater improvements in grain and dairy food quality were observed in the intervention arms.

CONCLUSIONS

The ADG database enabled ADG specific food group analysis, addressed food quality and showed the HealthTrack intervention increased adherence to dietary guidelines compared to usual care.

Safety and Efficacy of Using Nuts to Improve Bowel Health in Hemodialysis Patients

OBJECTIVE

Constipation is common in patients with end-stage kidney disease. Nondrug strategies to manage constipation are challenging because of dietary potassium, phosphate, and fluid restrictions. Nuts are a high-fiber food but are excluded from the diet because of the high potassium and phosphate content. The aim of this study was to examine the safety and efficacy of using nuts to improve constipation in adults undertaking hemodialysis (HD).

DESIGN AND METHODS

Adult patients undertaking HD were recruited to this nonrandomized, 10-week repeated measures, within-subject, pragmatic clinical trial, conducted in two HD units. The intervention consisted of consumption of 40g of raw almonds daily for four weeks, followed by a two-week washout and four-week control period. The primary safety outcome measures were change in predialysis serum potassium and phosphate levels. The primary efficacy outcome was reduction in constipation, measured using the Bristol Stool Form Scale and Palliative Care Outcome Scale (POS-S) renal symptom score. Secondary outcomes included quality of life, selected uremic toxins, cognition, gut microbiota profile, and symptom burden.

RESULTS

Twenty patients completed the trial (median age: 67 [interquartile range: 57.5-77.8] years, 51% male). After controlling for dialysis adequacy, anuria, dietary intake, bicarbonate, and parathyroid hormone, there were no statistically significant changes in serum potassium (P = 0.21) or phosphate (P = 0.16) associated with daily consumption of almonds. However, statistically significant improvements in constipation were seen at weeks 2, 3, 4, and 10. There were statistically significant improvements in quality of life (P = 0.030), overall symptom burden (P = 0.002), vomiting (P = 0.020), itching (P = 0.006), and skin changes (P = 0.002).

CONCLUSION

Daily consumption of almonds for four weeks was safe, effective, and well tolerated. Improvements in quality of life and symptom burden warrant further research to elucidate potential mechanisms. The findings support the potential reinclusion of foods such as nuts into the diet of patients who underwent HD.

Exploring perceptions, barriers and use of systematic reviews amongst nutrition professionals and nutrition students

AIM

Systematic reviews (SRs) are a core component of evidence-based practice and are widely used in developing nutrition policy. This study aimed to examine nutrition professionals and students' perceptions, barriers and use of SRs. A secondary aim was to examine confidence using and conducting SRs.

METHODS

A self-administered online survey was developed, pilot-tested and implemented via SurveyMonkey. The survey consisted of 29 items separated into demographics, perceptions, use, and knowledge of SRs, confidence in using and conducting SRs, and barriers to use and conduct of SRs. The survey was disseminated via professional newsletters and social media.

RESULTS

Ninety-four nutrition professionals/students completed the survey. Survey results indicated respondents valued SRs, with SRs used most commonly to update knowledge. While most respondents (67%) were confident in using SRs, many (59%) expressed a lack of confidence in conducting a SR. In particular, few respondents (12%) reported confidence in conducting meta-analyses. The majority of respondents were aware that SRs underpinned guidelines and nutrition resources, however, few (21%) respondents identified that self-substantiation of health claims were based on SRs. Time, access to scientific database, lack of workplace support and confidence were the main barriers to SRs use.

CONCLUSIONS

SRs were reported as being valued by nutrition professionals and students, though time constraints, a lack of confidence and organisations which did not prioritise research were barriers to conducting SRs. The findings of this survey highlight a need for training and education as potential strategies to promote SR engagement in nutrition professionals and students.

A Systematic Review of the Impact of Dietary Sodium on Autoimmunity and Inflammation Related to Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system. Current research into potential causes, risk factors, and treatment is largely based around the immune response involved in the pathophysiology of the disease, including factors that contribute to the augmentation of this immune response. This review aimed to determine the role of sodium as a risk factor for increased autoimmunity and inflammation in relation to MS pathogenesis. This systematic review searched the Scopus, MEDLINE, and PubMed scientific databases for studies related to MS and sodium. Studies were included if they addressed sodium intake and MS but were not limited to a disease type or to a study design. Study quality was assessed through the use of the quality rating checklist of the Academy of Nutrition and Dietetics. A total of 12 studies were included in the review, including human, animal, and cellular studies. The studies related to the proinflammatory effect of sodium, the blood-brain barrier, and an effect on autoimmunity. The data presented throughout this review provide insight into the emerging evidence base for sodium intake as a risk factor for MS disease progression and potentially onset of disease. More studies are needed to determine if the influence of sodium is as a single nutrient or has a combined effect as part of an overall eating pattern. This review was registered at PROSPERO as CRD42016039174.

Development of a Choline Database to Estimate Australian Population Intakes

The AUSNUT 2011-13 food composition database was expanded to include Australian choline values. The development began with a systematic literature review of published studies. Analytical data from the food studies were extracted and aligned with their equivalent AUSNUT food identification code. Global food composition databases containing choline values were matched to the remaining AUSNUT food codes, following the FAO INFOODS food matching guidelines, including adjustments for moisture and protein composition. Composite foods, and not further-specified foods, were developed using the Food Standards Australia New Zealand (FSANZ) recipe files. The completed choline database was then employed to analyse the Australian National Nutrition and Physical Activity Survey 2011-12, with population and sampling weightings applied. Survey respondents were classified into categories based on their level of choline intake and compared with the Australian Adequate Intake levels. Food sources of intake were also explored. Multiple linear regression models were developed for food group contributors to choline intake. Mean choline intakes varied from 151.50 mg for pregnant 14-18 years old, to 310.54 mg for 19-64 year old males. Less than 10% of the population by age and gender were achieving the Adequate Intake for choline. Eggs and their contributing food groups were the top ranked food sources of choline for the population.

Nutrient profiling and food prices: what is the cost of choosing healthier products?

BACKGROUND

The Health Star Rating (HSR) is a front-of-pack label designed to help Australian consumers identify healthier packaged foods. Price is an important determinant of food choice and yet no previous studies have examined the relationship between HSR and price. In the present study, we investigated whether (i) healthier packaged food products, as determined by HSR, are more expensive than less healthy alternatives and (ii) products displaying the HSR are more expensive than similar products that do not.

METHODS

Prices of three packaged foods categories (breakfast cereals, cereal-based bars and fruit juices) and nutrient data (to calculate HSR) were obtained from shopping receipts of approximately 1600 Australians between June 2014 and September 2016. Associations between HSR and price [per energy ($/100 kJ) and per unit ($/100 g)] for products of comparable package sizes were assessed by linear regression and the results are presented as differences in average price over the theoretical maximum range of HSR from 0.5 to 5 stars.

RESULTS

The HSR of products was not consistently related to price. Small positive associations were observed for juice ($0.08/100 mL; P = 0.03) and for cereal-based bars ($0.04/100 kJ; P = 0.02). No other associations between HSR and price were observed (P ≥ 0.23). Products that displayed the HSR were no more expensive on average than products that received a similar HSR but did not display the HSR (P ≥ 0.16).

CONCLUSIONS

In summary, the findings of the present study suggest that healthier packaged food products were not consistently more expensive than less healthy products and also that price is unlikely to be a barrier for consumers to use the HSR to select healthier packaged foods.

Dietary Patterns and Cardiovascular Disease: Insights and Challenges for Considering Food Groups and Nutrient Sources

PURPOSE OF REVIEW

The relationship between dietary patterns and cardiovascular disease has been the subject of much research, but an important methodological consideration is the interdependence between the nutrient composition of foods and the recognition of healthy dietary patterns. This review considers some of the challenges in researching dietary patterns with implications for translation to public health promotions.

RECENT FINDINGS

A number of statistical methods have emerged for analysing dietary patterns using population dietary data. There are limitations in the assumptions underpinning food categorisation, but this research is able to consistently identify foods and dietary patterns that are positively related to health. Aligned to this activity is the ongoing development of food composition databases which has its own limitations such as keeping up to date with changing foods and newly identified components, sampling of foods, and developments in chemical analytical methods. Finally, dietary patterns form the basis for current dietary guidelines and related public health-oriented programs, but the issues raised for research (e.g. food categorisation and cuisine influences on dietary patterns) can also translate to these settings. The study of dietary patterns in cardiovascular disease prevention presents with a number of methodological challenges relating to the way food groups are formed and the limitations of food composition databases. Added to this are new considerations for the environmental impact of recommended dietary patterns. Future research across the entire knowledge chain should target more accurate methods in a number of analytical areas.

The Role of Various Forms of Training on Improved Accuracy of Food-Portion Estimation Skills: A Systematic Review of the Literature

This study describes the types of food-portion tools used and changes in accuracy for food-portion size estimation by adult populations after an intervention of food-portion education and training. This systematic review searched 7 scientific databases. Only internally comparable study designs were included. Studies were tabulated for nutrition- and non-nutrition-trained university students and the general population. Included studies were assessed for level of evidence and quality, including risk of bias. Thirteen studies were reviewed, with 8 targeting university students. Food type, length of training, number of tools, and the impact of repeated use on food-portion estimation were summarized. Estimation accuracy calculations across studies were not consistent, and training was found to improve portion-size estimation accuracy in the short term (4 wk). Computer-based training tools only identified for the general population were equally or less effective and shifted estimation from under- to overestimation. This review suggests that education with food-portion tools may be effective in improving estimation skills in university-recruited participants and the general population. Computerized tools for university students are required, likely combined with other tools for improved estimation accuracy. The use of food models or multiple tools is more effective until a tailored computerized solution is developed. Repeated training is needed to maintain skills over time. This systematic review was registered with PROSPERO at http://bit.ly/2mZK3u3 as CRD42016038110.

Translating advice to eat more vegetables into practice: observations from a 12-month weight loss trial

OBJECTIVES

This study aimed to identify the main vegetable sources of overweight participants during a 12-month randomised controlled trial for weight loss.

METHODS

Secondary analysis using data from diet history interviews to determine changes to daily vegetable intake amounts and types throughout the trial at 0, 3 and 12 months.

RESULTS

Pre-trial 77% participants consumed frozen vegetables. At baseline (n = 113, 85 F), participants reported 345 ± 170 (56-920) g/day vegetables increasing to 498 ± 180 (146-930) g/day at 3 months and remaining stable at 475 ± 169(170-1053) g/day by 12 months (p = 0.001). At baseline, 32 of 34 different vegetable categories were reported, mainly tomato (69.9 g/day) and, potato (58.2 g/day). After 3 months (n = 109), seven vegetables remained in the top 10 reported (contributing 72%). Tomato remained top ranked to 12 months.

CONCLUSION

Following advice to consume more vegetables, consumption increased above the Australian Dietary recommendation of ~375 g/day. Tomatoes remained a mainstay regardless of the time of year, but choices changed with time. Frozen vegetables may be a feasible option.

Healthiness of Food and Beverages for Sale at Two Public Hospitals in New South Wales, Australia

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14(7%) fixed outlets and 16/70(23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

Exploring Data Quality Management within Clinical Trials

BACKGROUND

Clinical trials are an important research method for improving medical knowledge and patient care. Multiple international and national guidelines stipulate the need for data quality and assurance. Many strategies and interventions are developed to reduce error in trials, including standard operating procedures, personnel training, data monitoring, and design of case report forms. However, guidelines are nonspecific in the nature and extent of necessary methods.

OBJECTIVE

This article gathers information about current data quality tools and procedures used within Australian clinical trial sites, with the aim to develop standard data quality monitoring procedures to ensure data integrity.

METHODS

Relevant information about data quality management methods and procedures, error levels, data monitoring, staff training, and development were collected. Staff members from 142 clinical trials listed on the National Health and Medical Research Council (NHMRC) clinical trials Web site were invited to complete a short self-reported semiquantitative anonymous online survey.

RESULTS

Twenty (14%) clinical trials completed the survey. Results from the survey indicate that procedures to ensure data quality varies among clinical trial sites. Centralized monitoring (65%) was the most common procedure to ensure high-quality data. Ten (50%) trials reported having a data management plan in place and two sites utilized an error acceptance level to minimize discrepancy, set at <5% and 5 to 10%, respectively. The quantity of data variables checked (10-100%), the frequency of visits (once-a-month to annually), and types of variables (100%, critical data or critical and noncritical data audits) for data monitoring varied among respondents. The average time spent on staff training per person was 11.58 hours over a 12-month period and the type of training was diverse.

CONCLUSION

Clinical trial sites are implementing ad hoc methods pragmatically to ensure data quality. Findings highlight the necessity for further research into "standard practice" focusing on developing and implementing publically available data quality monitoring procedures.

Evaluation of Australian soup manufacturer compliance with national sodium reduction targets

AIM

Packaged foods dominate Australia's food supply and are important contributors to nutrition-related disease. To help address this problem, the Food and Health Dialogue (FHD) was launched in 2009, setting voluntary sodium reduction targets for various categories of packaged foods. The aim of this study was to examine the food industry's progress and compliance with the FHD sodium reduction targets for soup products.

METHODS

Nutritional information was collected from product labels of all soup products available from four major Australian supermarkets annually between 2011 and 2014. Products were assigned to categories in line with those in the FHD. The proportion of soup products meeting sodium reduction targets was examined by (i) soup category; (ii) FHD participant status; and (iii) manufacturer.

RESULTS

A 6% reduction in sodium levels in soups overall was found from 2011 to 2014 (P = 0.002). Significant reductions were observed for FHD participants (P < 0.05 for all) but not for non-participants. In 2014, 67% dry soups and 76% of wet soups met national sodium reduction targets.

CONCLUSIONS

Despite the majority of soup products meeting the sodium reduction targets specified by the FHD, re-evaluation of the targets may be required to further reduce sodium levels in soups. Manufacturers participating in the FHD are likely to be driving sodium reductions in the Australian soup market, further highlighting the need for continued government leadership in this area to ensure all manufacturers are actively involved in the process.