Development of the Menu Assessment Scoring Tool (MAST) to Assess the Nutritional Quality of Food Service Menus.

Preventing the rise in obesity is a global public health priority. Neighbourhood environments can help or undermine people's efforts to manage their weight, depending on availability of nutritious and nutrient-poor 'discretionary' foods. The proportion of household food budgets spent on eating outside the home is increasing. To inform nutrition policy at a local level, an objective assessment of the nutritional quality of foods and beverages on food service menus that is context-specific is needed. This study describes the development and piloting of the Menu Assessment Scoring Tool (MAST), used to assess the nutritional quality of food service menus in Australia. The MAST is a desk-based tool designed to objectively assess availability of nutrient-poor and absence of nutritious food and beverages on food service menus. A risk assessment approach was applied, using the best available evidence in an iterative way. MAST scores for 30 food service outlets in one Local Government Authority in Perth, Western Australia highlight opportunities for improvements. MAST is the first tool of its kind in Australia to assess the nutritional quality of food service menus. It was practical and feasible to use by public health nutritionists/dietitians and can be adapted to suit other settings or countries.

Food Outlets Dietary Risk (FODR) assessment tool: study protocol for assessing the public health nutrition risks of community food environments.

BACKGROUND: Availability and accessibility of nutritious foods can vary according to the food outlets present within a neighbourhood or community. There is increasing evidence that community food environments influence food choice, diet and the risk of diet-related chronic disease, however contemporary community food environments assessments (e.g. unhealthy fast food outlets versus healthy supermarkets or fruit and vegetable shops) may be too simplistic to accurately summarise the complexities of their impacts on food choice. This study protocol describes the development of the Food Outlets Dietary Risk (FODR) assessment tool for use by local government in Perth, Western Australia. METHODS: Similar to food safety risk assessment, the FODR assessment tool rates the potential harmful public health nutrition impact of food outlets by identifying and characterising the issues, and assessing the risk of exposure. Scores are attributed to six public health nutrition attributes: 1) availability of nutrient-poor foods; 2) availability of nutritious foods; 3) acceptability and appeal; 4) accessibility; 5) type of business operation; and 6) complex food outlet considerations. Food retail outlets are then classified as having a low, medium, high or very high dietary risk based on their total score. DISCUSSION: A local government administered tool to rate the public health nutrition risk of food outlets requires data which can be collected during routine assessments or sourced from the internet. The ongoing categorical classification of foods available within food outlets as either unhealthy or nutritious will require nutrition scientists' input. An objective risk assessment of the dietary impact of food retail outlets can guide local government planning, policies and interventions to create supportive community food environments. It is intended that locally relevant data can be sourced throughout Australia and in other countries to apply the local context to the FODR assessment tool. Utility and acceptability of the tool will be tested, and consultation with environmental health officers and public health practitioners will inform future iterations.

The Nature and Quality of Australian Supermarkets' Policies that can Impact Public Health Nutrition, and Evidence of their Practical Application: A Cross-Sectional Study.

Improving population diets is a public health priority, and calls have been made for corporations such as supermarkets to contribute. Supermarkets hold a powerful position within the food system, and one source of power is supermarket own brand foods (SOBFs). Many of the world's largest supermarkets have corporate social responsibility (CSR) policies that can impact public health, but little is known about their quality or practical application. This study examines the nature and quality of Australian supermarkets' CSR policies that can impact public health nutrition, and provides evidence of practical applications for SOBFs. A content analysis of CSR policies was conducted. Evidence of supermarkets putting CSR policies into practice was derived from observational audits of 3940 SOBFs in three large exemplar supermarkets (Coles, Woolworths, IGA) in Perth, Western Australia (WA). All supermarkets had some CSR policies that could impact public health nutrition; however, over half related to sustainability, and many lacked specificity. All supermarkets sold some nutritious SOBFs, using marketing techniques that made them visible. Findings suggest Australian supermarket CSR policies are not likely to adequately contribute to improving population diets or sustainability of food systems. Setting robust and meaningful targets, and improving transparency and specificity of CSR policies, would improve the nature and quality of supermarket CSR policies and increase the likelihood of a public health benefit.

Global supermarkets' corporate social responsibility commitments to public health: a content analysis.

BACKGROUND: Supermarkets have unprecedented political and economic power in the food system and an inherent responsibility to demonstrate good corporate citizenship via corporate social responsibility (CSR). The aim of this study was to investigate the world's largest and most powerful supermarkets' publically available CSR commitments to determine their potential impact on public health. METHODS: The world's largest 100 retailers were identified using the Global Powers of Retailing report. Thirty-one supermarkets that published corporate reports referring to CSR or sustainability, in English, between 2013 and 2018, were included and thematically analysed. RESULTS: Although a large number of themes were identified (n = 79), and there were differences between each business, supermarket CSR commitments focused on five priorities: donating surplus food to charities for redistribution to feed the hungry; reducing and recovering food waste; sustainably sourcing specific ingredients including seafood, palm oil, soy and cocoa; governance of food safety; and growing the number of own brand foods available, that are made by suppliers to meet supermarkets' requirements. CONCLUSIONS: CSR commitments made by 31 of the world's largest supermarkets showed they appeared willing to take steps to improve sustainable sourcing of specific ingredients, but there was little action being taken to support health and nutrition. Although some supermarket CSR initiatives showed promise, the world's largest supermarkets could do more to use their power to support public health. It is recommended they should: (1) transparently report food waste encompassing the whole of the food system in their waste reduction efforts; (2) support healthful and sustainable diets by reducing production and consumption of discretionary foods, meat, and other ingredients with high social and environmental impacts; (3) remove unhealthful confectionery, snacks, and sweetened beverages from prominent in-store locations; (4) ensure a variety of minimally processed nutritious foods are widely available; and (5) introduce initiatives to make healthful foods more affordable, support consumers to select healthful and sustainable foods, and report healthful food sales as a proportion of total food sales, using transparent criteria for key terms.

Alignment of Supermarket Own Brand Foods' Front-of-Pack Nutrition Labelling with Measures of Nutritional Quality: An Australian Perspective.

Two voluntary front-of-pack nutrition labels (FOPNL) are present in Australia: the government-led Health Star Ratings (HSR) and food industry-led Daily Intake Guide (DIG). Australia's two largest supermarkets are key supporters of HSR, pledging uptake on all supermarket own brand foods (SOBF). This study aimed to examine prevalence of FOPNL on SOBF, and alignment with patterns of nutritional quality. Photographic audits of all SOBF present in three large supermarkets were conducted in Perth, Western Australia, in 2017. Foods were classified as nutritious or nutrient-poor based on the Australian Guide to Healthy Eating (AGTHE), NOVA level of food processing, and HSR score. Most (81.5%) SOBF featured FOPNL, with only 55.1% displaying HSR. HSR was present on 69.2% of Coles, 54.0% of Woolworths, and none of IGA SOBF. Half (51.3%) of SOBF were classified as nutritious using the AGTHE, but using NOVA, 56.9% were ultra-processed foods. Nutrient-poor and ultra-processed SOBF were more likely than nutritious foods to include HSR, yet many of these foods achieved HSR scores of 2.5 stars or above, implying they were a healthy choice. Supermarkets have a powerful position in the Australian food system, and they could do more to support healthy food selection through responsible FOPNL.

The extent and nature of supermarket own brand foods in Australia: study protocol for describing the contribution of selected products to the healthfulness of food environments.

BACKGROUND: While public health experts have identified food environments as a driver of poor diet, they also hold great potential to reduce obesity, non-communicable diseases, and their inequalities. Supermarkets are the dominant retail food environment in many developed countries including Australia. The contribution of supermarket own brands to the healthfulness of retail food environments has not yet been explored. The aim of this protocol is to describe the methods developed to examine the availability, nutritional quality, price, placement and promotion of supermarket own brand foods within Australian supermarkets. METHODS: Photographic audits of all supermarket own brand foods present in three major food retail outlets were conducted. Two researchers conducted the supermarket audits in Perth, Western Australia in February 2017. Photographs showing the location of the in-store product display, location of products on shelves, use of display materials, and front-of-pack and shelf-edge labels were taken for each supermarket own brand food present. An electronic filing system was established for photographs from each of the supermarkets and an Excel database constructed. The following data were extracted from the photographs: front-of-pack product information (e.g. product and brand name, pack weight); packaging and label design attributes (e.g. country of origin; marketing techniques conveying value for money and convenience); shelf-edge label price and promotion information; placement and prominence of each product; and nutrition and health information (including supplementary nutrition information, nutrition and health claims, and marketing statements and claims). Nutritional quality of each product was assessed using the principles of the Australian Guide to Healthy Eating, the NOVA classification of level of food processing, and the Health Star Rating score displayed on the front-of-pack. DISCUSSION: Approximately 20,000 photographic images were collected for 3940 supermarket own brand foods present in this audit: 1812 in the Woolworths store, 1731 in the Coles store, and 397 in the IGA store. Analysis of findings will enable researchers to identify opportunities for interventions to improve the contribution of supermarket own brands to healthful retail food environments. This protocol is unique as it aims to investigate all aspects of retail food environments and address the contribution of supermarket own brands.

Can a Simple Dietary Index Derived from a Sub-Set of Questionnaire Items Assess Diet Quality in a Sample of Australian Adults?

Large, longitudinal surveys often lack consistent dietary data, limiting the use of existing tools and methods that are available to measure diet quality. This study describes a method that was used to develop a simple index for ranking individuals according to their diet quality in a longitudinal study. The RESIDential Environments (RESIDE) project (2004-2011) collected dietary data in varying detail, across four time points. The most detailed dietary data were collected using a 24-item questionnaire at the final time point (n = 555; age ≥ 25 years). At preceding time points, sub-sets of the 24 items were collected. A RESIDE dietary guideline index (RDGI) that was based on the 24-items was developed to assess diet quality in relation to the Australian Dietary Guidelines. The RDGI scores were regressed on the longitudinal sub-sets of six and nine questionnaire items at T4, from which two simple index scores (S-RDGI1 and S-RDGI2) were predicted. The S-RDGI1 and S-RDGI2 showed reasonable agreement with the RDGI (Spearman's rho = 0.78 and 0.84; gross misclassification = 1.8%; correct classification = 64.9% and 69.7%; and, Cohen's weighted kappa = 0.58 and 0.64, respectively). For all of the indices, higher diet quality was associated with being female, undertaking moderate to high amounts of physical activity, not smoking, and self-reported health. The S-RDGI1 and S-RDGI2 explained 62% and 73% of the variation in RDGI scores, demonstrating that a large proportion of the variability in diet quality scores can be captured using a relatively small sub-set of questionnaire items. The methods described in this study can be applied elsewhere, in situations where limited dietary data are available, to generate a sample-specific score for ranking individuals according to diet quality.

Proximity to Liquor Stores and Adolescent Alcohol Intake: A Prospective Study.

INTRODUCTION: Cross-sectional studies have reported associations between liquor store availability and alcohol use among adolescents, but few prospective studies have confirmed this association. The aim of this study was to examine whether proximity to liquor stores at age 14 years was associated with alcohol intake at ages 14, 17, and 20 years. METHODS: Participants of the Western Australian Pregnancy Cohort (Raine) Study (n=999) self-reported alcohol intake at age 14 years (early adolescence, 2003-2005); age 17 years (middle adolescence, 2006-2008); and age 20 years (late adolescence, 2009-2011). A GIS measured proximity to the closest liquor store from participants' home and school addresses at age 14 years. Regression analyses in 2017 assessed the relationship between distance to the closest liquor store around home, school, or both (≤800 m versus >800 m) and alcohol intake. RESULTS: In cross-sectional analyses (age 14 years), having a liquor store within 800 m of school was associated with ever having part of an alcoholic drink (OR=2.34, p=0.003). Also, having a liquor store within 800 m of home or school was associated with ever having part of an alcoholic drink (OR=1.49, p=0.029) and ever having engaged in heavy drinking (OR=1.79, p=0.023). In prospective analyses, liquor store proximity at age 14 years was a significant predictor of alcohol intake at age 17 years (OR=2.34, p=0.032) but not at age 20 years. CONCLUSIONS: Liquor store availability in early adolescence may be a risk factor for alcohol intake in early and middle, but not late, adolescence. Improved understanding of the longer-term impacts of liquor store exposure on sensitive populations could help inform future licensing regulations.

Dietary patterns, body mass index and inflammation: Pathways to depression and mental health problems in adolescents.

BACKGROUND: Observational studies suggest that dietary patterns may impact mental health outcomes, although biologically plausible pathways are yet to be tested. We aimed to elucidate the longitudinal relationship between dietary patterns, adiposity, inflammation and mental health including depressive symptoms in a population-based cohort of adolescents. METHODS: Data were provided from 843 adolescents participating in the Western Australian Pregnancy Cohort (Raine) Study at 14 and 17 years (y) of age. Structural equation modelling was applied to test our hypothesised models relating dietary patterns, energy intake and adiposity (body mass index) at 14 y to adiposity and the pro-inflammatory adipokine (leptin) and inflammation (high sensitivity C-reactive protein - hs-CRP) at 17 y, and these inflammatory markers to depressive symptoms (Beck Depression Inventory) and Internalising and Externalising Behavioral Problems (Child Behavior Check List Youth Self- Report) at 17 y. We further tested a reverse hypothesis model, with depression at 14 y as a predictor of dietary patterns at the same time-point. RESULTS: The tested models provided a good fit to the data. A 'Western' dietary pattern (high intake of red meat, takeaway, refined foods, and confectionary) at 14 y was associated with higher energy intake and BMI at 14 y, and with BMI and biomarkers of inflammation at 17 y (all p < .05). A 'Healthy' dietary pattern (high in fruit, vegetables, fish, whole-grains) was inversely associated with BMI and inflammation at 17 y (p < .05). Higher BMI at 14 y was associated with higher BMI (p < .01), leptin (p < .05), hs-CRP (p < .05), depressive symptoms (p < .05) and mental health problems (p < .05), all at 17 y. CONCLUSION: A 'Western' dietary pattern associates with an increased risk of mental health problems including depressive symptoms in adolescents, through biologically plausible pathways of adiposity and inflammation, whereas a 'Healthy' dietary pattern appears protective in these pathways. Longitudinal modelling into adulthood is indicated to confirm the complex associations of dietary patterns, adiposity, inflammation and mental health problems, including depressive symptoms.

A prospective investigation of dietary patterns and internalizing and externalizing mental health problems in adolescents.

Investigating protective and risk factors that influence mental health in young people is a high priority. While previous cross-sectional studies have reported associations between diet and mental health among adolescents, few prospective studies exist. The aim of this study was to examine prospective relationships between dietary patterns and mental health among adolescents participating in the Western Australian Pregnancy Cohort (Raine) Study. Self-report questionnaires were used to assess indicators of mental health (Youth Self-Report externalizing/internalizing T-scores) and Western and Healthy dietary patterns (identified using factor analysis) at 14 (2003-2005) and 17 years (2006-2008). Multivariate linear and logistic regression were used to assess relationships between dietary patterns and mental health. Complete data were available for 746 adolescents. In females only, the Western dietary pattern z-score at 14 years was positively associated with greater externalizing behaviors at 17 years (ß = 1.91; 95% CI: 0.04, 3.78) and a greater odds of having clinically concerning externalizing behaviors at 17 years (OR = 1.90; 95% CI: 1.06, 3.41). No other statistically significant associations were observed. Overall our findings only lend partial support to a link between diet and mental health. We found it to be specific to females consuming a Western dietary pattern and to externalizing behaviors. Future research on dietary patterns and mental health needs to consider possible sex differences and distinguish between different mental health outcomes as well as between healthy and unhealthy dietary patterns.

Individual, Social, and Environmental Correlates of Healthy and Unhealthy Eating.

BACKGROUND: Few studies use comprehensive ecological approaches considering multilevel factors to understand correlates of healthy (and unhealthy) dietary intake. The aim of this study was to examine the association between individual, social, and environmental factors on composite measures of healthy and unhealthy dietary intake in adults. METHOD: Participants (n = 565) of the Australian RESIDential Environments (RESIDE) project self-reported dietary intake, home food availability, and behavioral and perceived social and physical environmental influences on food choices. A geographic information system measured proximity of supermarkets from each participant's home. "Healthy" and "unhealthy" eating scores were computed based on adherence to dietary guidelines. Univariate and multivariate models were constructed using linear regression. RESULTS: After full adjustment, "healthy" eating (mean = 6.25, standard deviation [SD] = 1.95) was significantly associated with having confidence to prepare healthy meals (ß = 0.34; 95% confidence interval [CI] = [0.13, 0.55]); having more healthy (ß = 0.13; 95% CI = [0.09-0.16]) and fewer unhealthy (ß = -0.04; 95% CI = [-0.06, -0.02]) foods available at home; and having a supermarket within 800 meters of home (ß = 1.39; 95% CI = [0.37, 2.404]). "Unhealthy" eating (mean = 3.53, SD = 2.06) was associated with being male (ß = 0.39; 95% CI = [0.02, 0.75]), frequently eating takeaway (ß = 0.33; 95% CI = [0.21, 0.46]) and cafe or restaurant meals (ß = 0.20; 95% CI = [0.06, 0.33]) and having fewer healthy (ß = -0.07; 95% CI = [-0.10, -0.03]) and more unhealthy (ß = 0.09; 95% CI = [0.07, 0.10]) foods available within the home. CONCLUSION: Initiatives to improve adherence to dietary guidelines and reduce the consumption of unhealthy foods needs to be multifaceted; addressing individual factors and access to healthy food choices in both the home and neighborhood food environment. Ensuring proximity to local supermarkets, particularly in new suburban developments, appears to be an important strategy for facilitating healthy eating.

Not Just "A Walking the Dog": Dog Walking and Pet Play and Their Association With Recommended Physical Activity Among Adolescents.

PURPOSE: To examine the role of pet play and dog walking in children's and adolescents' leisure time, and the relationship between these activities and physical activity. DESIGN: The study design was observational. SETTING: The study setting was metropolitan Perth and nonmetropolitan regions in Western Australia. SUBJECTS: The study included 1097 primary school (mean age, 10.1 years; SD, 1.6 years) and 657 secondary school (mean age, 14.0 years; SD, 1.3 years) students. MEASURES: Validated measures of total physical activity, dog walking, and pet play activity (prevalence and time) were calculated. ANALYSIS: Generalized linear models tested for differences between proportions, while adjusting for socioeconomic status, age, and school-level clustering. RESULTS: Approximately one third of primary school and one quarter of secondary school students reported that they walked the dog at least once in the last week. Pet play was the most common play activity for primary and secondary school girls, and the second and third most popular play activity for secondary and primary school boys, respectively. Secondary school students who walked the dog or played with pets spent an average of 1 hour per week on each activity, and they were significantly more likely (p < .005) to meet national physical activity recommendations than secondary school students not reporting these activities. CONCLUSION: Given the significant proportion of young people who frequently engage in dog walking and pet play, and the high level of pet ownership in many Western countries, promotion of these activities to support young people's health is warranted.

Energy drink consumption is associated with anxiety in Australian young adult males.

BACKGROUND: Energy drinks are predominantly targeted to young adult consumers; however, there has been limited research into their effects on psychological functioning in this demographic group. This study examined cross-sectional associations between energy drink consumption and mental health in a population-based sample of young adults participating in the Western Australian Pregnancy Cohort (Raine) Study. METHODS: We used self-report questionnaires to assess energy drink consumption and mental health (Depression Anxiety Stress Scale-21; DASS-21) at the 20-year cohort follow-up. In the regression analyses, we considered associations between energy drink consumption (mL/day) and continuous DASS-21 scores, adjusting for sociodemographic variables, alcohol and drug use, physical activity, body mass index (BMI), and dietary intake. Our sample included 502 males and 567 females (mean age 20 ± 3 years). RESULTS: After adjusting for potential confounding factors and controlling for coexisting mental health problems, energy drink consumption (per 100 mL/day) was significantly associated with anxiety (but not depression or stress), and this relationship was found only in males (ß = 0.32; 95% CI = 0.05, 0.58). CONCLUSIONS: Our study found that energy drink consumption was associated with increased anxiety in young adult males. Further research into the possible contribution of energy drink use to the development of mental health problems in young adults is needed.

Energy drink consumption among young Australian adults: associations with alcohol and illicit drug use.

BACKGROUND: Energy drinks are becoming increasingly popular among young people. The purpose of this study was to determine the prevalence of energy drink consumption and its associations with socio-demographic characteristics, alcohol, cigarette and illicit drug use in a population-based sample of young adults participating in the Western Australian Pregnancy Cohort (Raine) Study. METHODS: We used self-administered questionnaires to assess energy drink consumption patterns, alcohol intake, cigarette and illicit drug use at the 20-year cohort follow-up. Data was also collected on socio-demographics, physical activity, body mass index (BMI) and dietary intake. Our sample included 1234 participants (47% male, mean age 20 ± 0.5 years). We considered energy-drink consumption as a categorical (users versus non-users) variable. RESULTS: Overall, 48% of participants consumed energy drinks at least once per month, with an average intake of 1.31 ± 0.75 cans per day amongst energy drink users. The most significant correlates of energy drink use were being in part-time or full-time employment, being male, being a cigarette smoker, having heavier alcoholic spirit consumption patterns and being an ecstasy user (all p<0.05). No significant associations were observed with BMI or dietary intake. CONCLUSIONS: Australian energy drink users tend to have heavier alcohol consumption patterns be a cigarette smoker and use illicit drugs relative to non-users. More research is needed regarding the health risks associated with energy drink use in young adults, including their possible role in the development of substance abuse problems.

Measurement of children's physical activity using a pedometer with a built-in memory.

OBJECTIVES: We evaluated the accuracy of the Accusplit AH120 pedometer (built-in memory) for recording step counts of children during treadmill walking against (1) observer counted steps and (2) concurrently measured steps using the previously validated Yamax Digiwalker SW-700 pedometer. DESIGN: This was a cross-sectional validation study performed under controlled settings. METHODS: Forty five 9-12-year-olds walked on treadmills at speeds of 42, 66 and 90m/min to simulate slow, moderate and fast walking wearing Accusplit and Yamax pedometers concurrently on their right hip. Observer counted steps were captured by video camera and manually counted. Absolute value of percent error was calculated for each comparison. Bland-Altman plots were constructed to show the distribution of the individual (criterion-comparison) scores around zero. RESULTS: Both pedometers under-recorded observer counted steps at all three walk speeds. Absolute value of percent error was highest at the slowest walk speed (Accusplit=46.9%; Yamax=44.1%) and lowest at the fastest walk speed (Accusplit=8.6%; Yamax=8.9%). Bland-Altman plots showed high agreement between the pedometers for all three walk speeds. CONCLUSIONS: Using pedometers with built-in memory capabilities eliminates the need for children to manually log step counts daily, potentially improving data accuracy and completeness. Step counts from the Accusplit (built-in memory) and Yamax (widely used) pedometers were comparable across all speeds, but their level of accuracy was dependent on walking pace. Pedometers should be used with caution in children as they significantly undercount steps, and this error is greatest at slower walk speeds.

Increasing children's physical activity: individual, social, and environmental factors associated with walking to and from school.

BACKGROUND: Efforts to increase the prevalence of children's active school transport require evidence to inform the development of comprehensive interventions. This study used a multilevel ecological framework to investigate individual, social, and environmental factors associated with walking to and from school among elementary school-aged children, stratified by gender. METHOD: Boys aged 10 to 13 years (n = 617) and girls aged 9 to 13 years (n = 681) attending 25 Australian primary schools located in high or low walkable neighborhoods completed a 1-week travel diary and a parent/child questionnaire on travel habits and attitudes. RESULTS: Boys were more likely (odds ratio [OR] = 3.37; p < .05) to walk if their school neighborhood had high connectivity and low traffic and less likely to walk if they had to cross a busy road (OR = 0.49; p < .05). For girls, confidence in their ability to walk to or from school without an adult (OR = 2.03), school encouragement (OR = 2.43), scheduling commitments (OR = 0.41), and parent-perceived convenience of driving (OR = 0.24) were significantly associated (p < .05) with walking. Irrespective of gender and proximity to school, child-perceived convenience of walking (boys OR = 2.17 and girls OR = 1.84) and preference to walk to school (child perceived, boys OR = 5.57, girls OR = 1.84 and parent perceived, boys OR = 2.82, girls OR = 1.90) were consistently associated (p < .05) with walking to and from school. CONCLUSION: Although there are gender differences in factors influencing children walking to and from school, proximity to school, the safety of the route, and family time constraints are consistent correlates. These need to be addressed if more children are to be encouraged to walk to and from school.