Production and conservation of nutrient-rich small fish (SIS) in ponds and wetlands for nutrition security and livelihoods in South Asia: Proceedings of a World Bank/SAFANSI funded regional workshop on small fish and nutrition, Dhaka, Bangladesh, 1st - 2nd March 2014

Small indigenous fish species (SIS) are an important source of essential macro- and micronutrients that can play an important role in the elimination of malnutrition and micronutrient deficiencies in the populations of many South and Southeast Asian countries. Of the 260 freshwater fish species in Bangladesh, more than 140 are classified as SIS and are an integral part of the rural Bangladeshi diet. As many SIS are eaten whole, with organs and bones, they contain high amounts of vitamins and minerals, including calcium, and iron and zinc. Some SIS, such as mola, are also rich in vitamin A. SIS are often cooked with vegetables and a little oil, so they contribute to the food diversity of the rural poor.SIS are recognized as a major animal-source food group, contributing to improved food and nutrition security and livelihoods of the people of South and Southeast Asia. The purpose of this workshop is to bring together policy makers, extension agents, researchers, non-governmental and development organizations to share knowledge about small fish, their contribution to better nutrition, production technologies, and strategies for wider dissemination of pond culture and wetland based-production and conservation technologies. The workshop is expected to generate ideas for further research and development of sustainable technologies for production, management and conservation of SIS for the benefit of the people of Bangladesh as well as the South and Southeast Asian region.

Early nutrition and eczema in infancy

Eczema prevalence rates among Irish infants are unreported, despite eczema being the most common inflammatory condition of infancy. Maternal and infant nutritional status including vitamin D and other fat-soluble vitamins as well as early infant feeding have been linked with eczema initiation and development. Therefore, early nutrition could be a potential modifiable risk factor. The objective of this thesis was to prospectively describe early infant feeding and complementary feeding practices, to evaluate infant vitamin D supplementation practice, to quantify cord serum 25-hydroxyvitamin D [25(OH)D] and propose reference intervals for vitamin D metabolites, to report eczema prevalence and explore the potential role of infant nutrition and eczema. These research needs were investigated through the Cork BASELINE (Babies After SCOPE: Evaluating the Longitudinal Impact with Neurological and Nutritional Endpoints) Birth Cohort Study (n 2137). This thesis was the first comprehensive report from the birth cohort, therefore it was important to describe the cohort sociodemographic profile. Although socio-demographic characteristics compared well with national data, there was an over-representation of educated mothers which may limit the generalizability of the results. From August 2008 through November 2011, comprehensive postnatal assessments were completed at day 2 and at 2, 6, 12 and 24 months. Breastfeeding rates were low, while complementary feeding practices were broadly compliant with national guidelines. The implementation of a national infant vitamin D supplementation policy had a major impact on supplementation practice. Low levels of serum 25(OH)D were universal among Irish neonates. Eczema is a complex and multifaceted disease, which is increasing globally. This was the first report of eczema prevalence data among Irish infants which compared with international reports. Given the high prevalence and considerable burden eczema has on the lives of sufferers, intensive research efforts to identify a cause and therapeutic strategies to prevent/reduce eczema was re-emphasized in this thesis.

REDUCING DIESEL DEPENDENCE IN NUNAVUT: INTEGRATING RENEWABLE ENERGY TECHNOLOGIES THROUGH POLICY ACTIONS

In the last fifty years, Nunavut has developed a deep dependence on diesel for virtually all of its energy needs, including electricity. This dependence has created a number of economic, environmental and health related challenges in the territory, with an estimated 20% of the territory’s annual budget being spent on energy, thereby limiting the Government of Nunavut’s ability to address other essential infrastructure and societal needs, such as education, nutrition and health care and housing. One solution to address this diesel dependency is the use of renewable energy technologies (RETs), such as wind, solar and hydropower. As such, this thesis explores energy alternatives in Nunavut, and through RETScreen renewable energy simulations, found that solar power and wind power are technically viable options for Nunavut communities and a potentially successful means to offset diesel-generated electricity in Nunavut. However, through this analysis it was also discovered that accurate data or renewable resources are often unavailable for most Nunavut communities. Moreover, through qualitative open-ended interviews, the perspectives of Nunavut residents with regards to developing RETs in Nunavut were explored, and it was found that respondents generally supported the use of renewable energy in their communities, while acknowledging that there still remains a knowledge gap among residents regarding renewable energy, stemming from a lack of communication between the communities, government and the utility company. In addition, the perceived challenges, opportunities and gaps that exist with regards to renewable energy policy and program development were discussed with government policy-makers through further interviews, and it was discovered that often government departments work largely independently of each other rather than collaboratively, creating gaps and oversights in renewable energy policy in Nunavut. Combined, the results of this thesis were used to develop a number of recommended policy actions that could be undertaken by the territorial and federal government to support a shift towards renewable energy in order to develop a sustainable and self-sufficient energy plan in Nunavut. They include: gathering accurate renewable resource data in Nunavut; increasing community consultations on the subject of renewable energy; building strong partnerships with universities, colleges and industry; developing a knowledge sharing network; and finally increasing accessibility to renewable energy programs and policies in Nunavut.

Attitudinal and demographic determinants of diet quality and implications for policy targeting

Background:  Poor diet quality is a major public health concern that has prompted governments to introduce a range of measures to promote healthy eating. For these measures to be effective, they should target segments of the population with messages relevant to their needs, aspirations and circumstances. The present study investigates the extent to which attitudes and constraints influence healthy eating, as well as how these vary by demographic characteristics of the UK population. It further considers how such information may be used in segmented diet and health policy messages. Methods:  A survey of 250 UK adults elicited information on conformity to dietary guidelines, attitudes towards healthy eating, constraints to healthy eating and demographic characteristics. Ordered logit regressions were estimated to determine the importance of attitudes and constraints in determining how closely respondents follow healthy eating guidelines. Further regressions explored the demographic characteristics associated with the attitudinal and constraint variables. Results:  People who attach high importance to their own health and appearance eat more healthily than those who do not. Risk-averse people and those able to resist temptation also eat more healthily. Shortage of time is considered an important barrier to healthy eating, although the cost of a healthy diet is not. These variables are associated with a number of demographic characteristics of the population; for example, young adults are more motivated to eat healthily by concerns over their appearance than their health. Conclusions:  The approach employed in the present study could be used to inform future healthy eating campaigns. For example, messages to encourage the young to eat more healthily could focus on the impact of diets on their appearance rather than health.

Policy interventions to promote healthy eating: a review of what works, what does not and what is promising

Unhealthy diets can lead to various diseases, which in turn can translate into a bigger burden for the state in the form of health services and lost production. Obesity alone has enormous costs and claims thousands of lives every year. Although diet quality in the European Union has improved across countries, it still falls well short of conformity with the World Health Organization dietary guidelines. In this review, we classify types of policy interventions addressing healthy eating and identify through a literature review what specific policy interventions are better suited to improve diets. Policy interventions are classified into two broad categories: information measures and measures targeting the market environment. Using this classification, we summarize a number of previous systematic reviews, academic papers, and institutional reports and draw some conclusions about their effectiveness. Of the information measures, policy interventions aimed at reducing or banning unhealthy food advertisements generally have had a weak positive effect on improving diets, while public information campaigns have been successful in raising awareness of unhealthy eating but have failed to translate the message into action. Nutritional labeling allows for informed choice. However, informed choice is not necessarily healthier; knowing or being able to read and interpret nutritional labeling on food purchased does not necessarily result in consumption of healthier foods. Interventions targeting the market environment, such as fiscal measures and nutrient, food, and diet standards, are rarer and generally more effective, though more intrusive. Overall, we conclude that measures to support informed choice have a mixed and limited record of success. On the other hand, measures to target the market environment are more intrusive but may be more effective.

Rural-urban disparities in child nutrition in Bangladesh and Nepal

Background The persistence of rural-urban disparities in child nutrition outcomes in developing countries alongside rapid urbanisation and increasing incidence of child malnutrition in urban areas raises an important health policy question - whether fundamentally different nutrition policies and interventions are required in rural and urban areas. Addressing this question requires an enhanced understanding of the main drivers of rural-urban disparities in child nutrition outcomes especially for the vulnerable segments of the population. This study applies recently developed statistical methods to quantify the contribution of different socio-economic determinants to rural-urban differences in child nutrition outcomes in two South Asian countries – Bangladesh and Nepal. Methods Using DHS data sets for Bangladesh and Nepal, we apply quantile regression-based counterfactual decomposition methods to quantify the contribution of (1) the differences in levels of socio-economic determinants (covariate effects) and (2) the differences in the strength of association between socio-economic determinants and child nutrition outcomes (co-efficient effects) to the observed rural-urban disparities in child HAZ scores. The methodology employed in the study allows the covariate and coefficient effects to vary across entire distribution of child nutrition outcomes. This is particularly useful in providing specific insights into factors influencing rural-urban disparities at the lower tails of child HAZ score distributions. It also helps assess the importance of individual determinants and how they vary across the distribution of HAZ scores. Results There are no fundamental differences in the characteristics that determine child nutrition outcomes in urban and rural areas. Differences in the levels of a limited number of socio-economic characteristics – maternal education, spouse’s education and the wealth index (incorporating household asset ownership and access to drinking water and sanitation) contribute a major share of rural-urban disparities in the lowest quantiles of child nutrition outcomes. Differences in the strength of association between socio-economic characteristics and child nutrition outcomes account for less than a quarter of rural-urban disparities at the lower end of the HAZ score distribution. Conclusions Public health interventions aimed at overcoming rural-urban disparities in child nutrition outcomes need to focus principally on bridging gaps in socio-economic endowments of rural and urban households and improving the quality of rural infrastructure. Improving child nutrition outcomes in developing countries does not call for fundamentally different approaches to public health interventions in rural and urban areas.

Lay people's views of school food policy options: associations with confidence, personal values and demographics

A random population survey administered by mail to examine lay people's views of children's food policies and their associations with demographics, personal values and confidence in authorities was conducted among adults in Victoria, Australia. Three hundred and seventy-seven people responded (response rate 57.6%). The questionnaire contained 35 items about children's healthy eating policy options plus details like personal values, confidence and demographic items. There was widespread support for healthy school food policies. The strongest support was for life skills education and school-based nutrition and physical education programmes. Many age-related associations indicated that people >48 years were more in favour of healthy eating policies than younger people. There were fewer statistically significant associations with parent status and sex. In contrast, many associations showed that respondents with strong equity–harmony values and those with least confidence in the authorities were most in favour of healthy eating policies for schoolchildren. It is concluded that there is widespread support for school-based health and nutrition education and for active school food policies. However, differences between demographic and values groups suggest the need for caution in the promotion of public health nutrition initiatives among schoolchildren.

Migrants getting fat in Australia: acculturation and its effects on the nutrition and physical activity of African migrants to developed countries

Obesity is a significant health problem in Australia and other developed countries and acculturation is one fo the many risk factors. This new book summarizes acculturation and anthropometric outcomes among sub-Saharan African migrants in Australia. The book further examines the relationship between acculturation and food, energy and nutrient intake and physical activity. Some policy recommendations are proposed.

Public health nutrition : from principles to practice

A systematic, research-based overview of the central principles and practice issues in the growing field of public health nutrition. With chapters by leading international experts, this is essential reading for practitioners and students in public health, nutrition, health policy and related fields.

Conceptualising the policy practice and behavioural research relationship

Background
Policy is frequently identified in the behavioural nutrition and physical activity research literature as a necessary component of effective research and practice. The purpose of this commentary is to promote a dialogue to contribute towards the further development of conceptual understandings and theories of the relationship between policy practice and behavioural research and how these two activities might work synergistically to improve public health outcomes.

Methods
Drawing on policy and public health literature, this commentary presents a a conceptual model of the interaction and mediation between nutrition and physical activity-relevant policy and behavioural nutrition and physical activity research, environments, behaviours and public health implications. The selling of food in school canteens in several Australian states is discussed to illustrate components of the relationship and the interactions among its components.

Results
The model depicts a relationship that is interdependent and cyclic. Policy contributes to the relationship through its role in shaping environmental and personal-cognitive determinants of behaviours and through these determinants it can induce behaviour change. Behavioural research describes behaviours, identifies determinants of behaviour change and therefore helps inform policy development and monitor and evaluate its impact.

Conclusion
The model has implications for guiding behavioural research and policy practice priorities to promote public health outcomes. In particular, we propose that policy practice and behavioural research activities can be strengthened by applying to each other the theories from the scientific disciplines informing these respective activities. Behavioural science theories can be applied to help understand policy-making and assist with disseminating research into policy and practice. In turn, policy science theories can be applied to support the 'institutionalisation' of commitments to ongoing behavioural research.

The effectiveness of nutrition interventions on dietary outcomes by relative social disadvantage : a systematic review

Objective: To determine whether nutrition interventions widen dietary inequalities across socioeconomic status groups.

Design: Systematic review of interventions that aim to promote healthy eating.

Data sources: CINAHL and MEDLINE were searched between 1990 and 2007.

Review methods: Studies were included if they were randomised controlled trials or concurrent controlled trials of interventions to promote healthy eating delivered at a group level to low socioeconomic status groups or studies where it was possible to disaggregate data by socioeconomic status.

Results: Six studies met the inclusion criteria. Four were set in educational setting (three elementary schools, one vocational training). The first found greater increases in fruit and vegetable consumption in children from high-income families after 1 year (mean difference 2.4 portions per day, p<0.0001) than in children in low-income families (mean difference 1.3 portions per day, p<0.0003). The second did not report effect sizes but reported the nutrition intervention to be less effective in disadvantaged areas (p<0.01). The third found that 24-h fruit juice and vegetable consumption increased more in children born outside the Netherlands ("non-native") after a nutrition intervention (beta coefficient = 1.30, p<0.01) than in "native" children (beta coefficient = 0.24, p<0.05). The vocational training study found that the group with better educated participants achieved 34% of dietary goals compared with the group who had more non-US born and non-English speakers, which achieved 60% of dietary goals. Two studies were conducted in primary care settings. The first found that, as a result of the intervention, the difference in consumption of added fat between the intervention and the control group was –8.9 g/day for blacks and –12.0 g/day for whites (p<0.05). In the second study, there was greater attrition among the ethnic minority participants than among the white participants (p<0.04).

Conclusions: Nutrition interventions have differential effects by socioeconomic status, although in this review we found only limited evidence that nutrition interventions widen dietary inequalities. Due to small numbers of included studies, the possibility that nutrition interventions widen inequalities cannot be excluded. This needs to be considered when formulating public health policy.

Nutrition and disease burden in Australia : intervening for the nation's health

Editorial on public health policy to improve health of Australians

Moving beyond 'rates, roads and rubbish' : how do local governments make choices about healthy public policy to prevent obesity?

While the causes of obesity are well known traditional education and treatment strategies do not appear to be making an impact. One solution as part of a broader complimentary set of strategies may be regulatory intervention at local government level to create environments for healthy nutrition and increased physical activity. Semi structured interviews were conducted with representatives of local government in Australia. Factors most likely to facilitate policy change were those supported by external funding, developed from an evidence base and sensitive to community and market forces. Barriers to change included a perceived or real lack of power to make change and the complexity of the legislative framework. The development of a systematic evidence base to provide clear feedback on the size and scope of the obesity epidemic at a local level, coupled with cost benefit analysis for any potential regulatory intervention, are crucial to developing a regulatory environment which creates the physical and social environment required to prevent obesity.

Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.