Evidence-informed process to identify policies that will promote a healthy food environment in the Pacific Islands

Objective: To implement a systematic evidence-informed process to enable Fiji and Tonga to identify the most feasible and targeted policy interventions which would have most impact on diet-related non-communicable diseases.

Design: A multisectoral stakeholder group of policy advisers was formed in each country. They used participatory approaches to identify the problem policies and gaps contributing to an unhealthy food environment. Potential solutions to these problems were then identified, and were assessed by them for feasibility, effectiveness, cost-effectiveness and side-effects. Data were gathered on the food and policy environment to support the assessments. A shortlist of preferred policy interventions for action was then developed.

Results: Sixty to eighty policy problems were identified in each country, affecting areas such as trade, agriculture, fisheries and pricing. Up to 100 specific potential policy solutions were then developed in each country. Assessment of the policies highlighted relevant problem areas including poor feasibility, limited effectiveness or cost-effectiveness and serious side-effects. A shortlist of twenty to twenty-three preferred new policy options for action in each country was identified.

Conclusions: Policy environments in these two countries were not conducive to supporting healthy eating. Substantial areas of potential action are possible, but some represent better choices. It is important for countries to consider the impact of non-health policies on diets.

Building an economic case for food interventions in the pacific

Diet-related health problems are a major issue throughout the Pacific region. Micronutrient deficiencies are widespread and rates of non-communicable diseases are increasing. There is a need for food-related policy interventions to improve the quality of the food supply and to enhance access to a healthy diet. To support the promotion and eventual implementation of these interventions, it is vital that the costs and impacts of the interventions are known. This paper outlines a project being undertaken in the region to develop cost-effectiveness models for food interventions in order to help build the case for action.

Integrating agriculture and food policy to achieve sustainable peri-urban fruit and vegetable production in Victoria, Australia

Efforts to increase fruit and vegetable consump­tion are a significant aspect of national approaches to preventive health. However, policy frameworks for increasing fruit and vegetable consumption rarely take an integrated food-systems approach that includes a focus on production. In this policy analysis and commentary we examine fruit and vegetable production in peri-urban areas of Melbourne in Victoria, Australia, and highlight the significance of emerging environmental and eco­nomic pressures on fruit and vegetable production. This examination will be of interest to other locations around the world also experiencing pressure on their peri-urban agriculture. These pressures suggest that the availability and afforda­bility of fruit and vegetable supplies cannot be taken for granted, and that future initiatives to increase fruit and vegetable consumption should include a focus on sustainable production. Threats to production that include environmental pressures, together with the loss and cost of peri-urban agri­cultural land and a cost-price squeeze due to rising input costs and low farm-gate prices, act in combi­nation to threaten the viability of the Victorian fruit and vegetable industries. We pro­pose that policy initiatives to increase fruit and vegetable consumption should include measures to address the pressures facing production, and that the most effective policy responses are likely to be integrated approaches that aim to increase fruit and vegetable availability and affordability through innovative solutions to problems of production and distribu­tion. Some brief examples of potential integrated policy solutions are identified to illu­strate the possibilities and stimulate discussion.

Modelling of potential food policy interventions in Fiji and Tonga and their impacts on noncommunicable disease mortality

Background: To compare the likely costs and benefits of a range of potential policy interventions in Fiji and Tonga targeted at diet-related noncommunicable diseases (NCDs), in order to support more evidence-based decision-making.

Method: A relatively simple and quick macro-simulation methodology was developed. Logic models were developed by local stakeholders and used to identify costs and dietary impacts of policy changes. Costs were confined to government costs, and excluded cost offsets. The best available evidence was combined with local data to model impacts on deaths from noncommunicable diseases over the lifetime of the target population. Given that the modelling necessarily entailed assumptions to compensate for gaps in data and evidence, use was made of probabilistic uncertainty analysis.

Results: Costs of implementing policy changes were generally low, with the exception of some requiring additional long-term staffing or construction activities. The most effective policy options in Fiji and Tonga targeted access to local produce and high-fat meats respectively, and were estimated to avert approximately 3% of diet-related NCD deaths in each population. Many policies had substantially lower benefits. Cost-effectiveness was higher for the low-cost policies. Similar policies produced markedly different results in the two countries.

Conclusion: Despite the crudeness of the method, the consistent modelling approach used across all the options, allowed reasonable comparisons to be made between the potential policy costs and impacts. This type of modelling can be used to support more evidence-based and informed decision-making about policy interventions and facilitate greater use of policy to achieve a reduction in NCDs.

Supermarket Healthy Eating for Life (SHELf): protocol of a randomised controlled trial promoting healthy food and beverage consumption through price reduction and skill-building strategies

Background: In the context of rising food prices, there is a need for evidence on the most effective approaches for promoting healthy eating. Individually-targeted behavioural interventions for increasing food-related skills show promise, but are unlikely to be effective in the absence of structural supports. Fiscal policies have been advocated as a means of promoting healthy eating and reducing obesity and nutrition-related disease, but there is little empirical evidence of their effectiveness. This paper describes the Supermarket Healthy Eating for LiFe (SHELf) study, a randomised controlled trial to investigate effectiveness and cost-effectiveness of a tailored skill-building intervention and a price reduction intervention, separately and in combination, against a control condition for promoting purchase and consumption of healthy foods and beverages in women from high and low socioeconomic groups.
Methods/design: SHELf comprises a randomised controlled trial design, with participants randomised to receive either (1) a skill-building intervention; (2) price reductions on fruits, vegetables and low-joule soft drink beverages and water; (3) a combination of skill-building and price reductions; or (4) a control condition. Five hundred women from high and low socioeconomic areas will be recruited through a store loyalty card program and local media. Randomisation will occur on receipt of informed consent and baseline questionnaire. An economic evaluation from a societal perspective using a cost-consequences approach will compare the costs and outcomes between intervention and control groups.
Discussion: This study will build on a pivotal partnership with a major national supermarket chain and the Heart Foundation to investigate the effectiveness of intervention strategies aimed at increasing women’s purchasing and consumption of fruits and vegetables and decreased purchasing and consumption of sugar-sweetened beverages. It will be among the first internationally to examine the effects of two promising approaches - skill-building and price reductions - on diet amongst women.

Baby boomers' desires for future health and food services

Purpose – The purpose of this paper is to identify food and health services desired by baby boomers and to examine their likely antecedents.

Design/methodology/approach – A random sample of baby boomers in Victoria, Australia (n=1,108) completed a postal survey and rated the desirability of 13 post retirement food and health services.

Findings – The strongest demand was expressed for low cost fruit and vegetables, 24-hour GP services, environmentally friendly foods, and friendly places to meet friends and exercise, among others. Generally, psychographic variables were key predictors of demand for social (health) services, food services, and vitamin pills and herbal remedies. Demand for food services was associated with universalism values.

Research limitations/implications – The cross-sectional design prevents causal attributions; however, the findings suggest that baby boomers' demand for services falls into three groups, which are related to their psychographic characteristics.

Originality/value – Consideration of these desired services may facilitate the planning of future health and food services for this broad age group.

Associations between mothers’ perceptions of the cost of fruit and vegetables and children’s diets : Will children pay the price?

Background/Objectives:
Perceptions that fruit and vegetables are expensive are more common among the socio-economically disadvantaged groups and are linked to poor dietary outcomes. Such perceptions may be exacerbated in countries recently affected by natural disasters, where devastation of fruit and vegetable crops has resulted in increase in prices of fruit and vegetables. Examining the associations of perceptions of fruit and vegetable affordability and children's diets can offer insights into how the high prices of fruit and vegetables might have an impact on the diets of children.
Subjects/Methods:
We analysed the data from 546 socio-economically disadvantaged mother–child pairs to assess the relationship between maternal perceptions of fruit and vegetable affordability and the diets of their children.
Results:
Fruit consumption was lower among children whose mothers felt the cost of fruit was too high. Maternal perceptions of fruit and vegetable affordability were not associated with any other aspect of child's diet.
Conclusions:
Our results suggest a possible role for maternal perceptions of fruit affordability in children's diet, though further research is warranted.

Does agricultural food provide a good alternative to a natural diet for body store deposition in geese?

Over the past decades most goose populations have become increasingly dependent on agricultural crops during wintering and migration periods. The suitability of agricultural crops to support all nutritional requirements of migratory geese for the deposition of body stores has been questioned; feeding on agricultural crops may yield higher rates of fat deposition at the cost of reduced protein accretion due to an unbalanced diet. We compared amino-acid composition of forage, and investigated food-habitat use and dynamics and composition of body stores deposited by barnacle geese feeding on agricultural pasture and in natural salt marsh during spring migratory preparation. Overall content and composition of amino acids was similar among forage from both habitats and appeared equally suitable for protein accretion. There was no relationship between body composition of geese and their preferred food habitat. Fat and wet protein contributed with 67% and 33%, respectively, to body stores gained at a rate of 11 g/d throughout the one-month study period. We found no evidence of impaired protein accretion in geese using agricultural grassland compared to natural salt marsh. Our study supports the hypothesis that the expansion of feeding habitat by including agricultural grassland has played an important role in the recent growth of the East Atlantic flyway population of barnacle geese and other herbivorous waterbirds. Feeding refuges of improved grassland provide geese with an adequate diet for the deposition of body stores crucial for spring migration and subsequent reproduction, thereby alleviating the conflict with agriculture.

Energetic cost of bot fly parasitism in free-ranging eastern chipmunks

The energy and nutrient demands of parasites on their hosts are frequently invoked as an explanation for negative impacts of parasitism on host survival and reproductive success. Although cuterebrid bot flies are among the physically largest and most-studied insect parasites of mammals, the only study conducted on metabolic consequences of bot fly parasitism revealed a surprisingly small effect of bot flies on host metabolism. Here we test the prediction that bot fly parasitism increases the resting metabolic rate (RMR) of free-ranging eastern chipmunks (Tamias striatus), particularly in juveniles who have not previously encountered parasites and have to allocate energy to growth. We found no effect of bot fly parasitism on adults. In juveniles, however, we found that RMR strongly increased with the number of bot fly larvae hosted. For a subset of 12 juveniles during a year where parasite prevalence was particularly high, we also compared the RMR before versus during the peak of bot fly prevalence, allowing each individual to act as its own control. Each bot fly larva resulted in a ~7.6% increase in the RMR of its host while reducing juvenile growth rates. Finally, bot fly parasitism at the juvenile stage was positively correlated with adult stage RMR, suggesting persistent effects of bot flies on RMR. This study is the first to show an important effect of bot fly parasitism on the metabolism and growth of a wild mammal. Our work highlights the importance of studying cost of parasitism over multiple years in natural settings, as negative effects on hosts are more likely to emerge in periods of high energetic demand (e.g. growing juveniles) and/or in harsh environmental conditions (e.g. low food availability).

Stores healthy options project in remote indigenous communities (SHOP@RIC): a protocol of a randomised trial promoting healthy food and beverage purchases through price discounts and in-store nutrition education

Background
Indigenous Australians suffer a disproportionate burden of preventable chronic disease compared to their non-Indigenous counterparts – much of it diet-related. Increasing fruit and vegetable intakes and reducing sugar-sweetened soft-drink consumption can reduce the risk of preventable chronic disease. There is evidence from some general population studies that subsidising healthier foods can modify dietary behaviour. There is little such evidence relating specifically to socio-economically disadvantaged populations, even though dietary behaviour in such populations is arguably more likely to be susceptible to such interventions.

This study aims to assess the impact and cost-effectiveness of a price discount intervention with or without an in-store nutrition education intervention on purchases of fruit, vegetables, water and diet soft-drinks among remote Indigenous communities.

Methods/Design
We will utilise a randomised multiple baseline (stepped wedge) design involving 20 communities in remote Indigenous Australia. The study will be conducted in partnership with two store associations and twenty Indigenous store boards. Communities will be randomised to either i) a 20% price discount on fruit, vegetables, water and diet soft-drinks; or ii) a combined price discount and in-store nutrition education strategy. These interventions will be initiated, at one of five possible time-points, spaced two-months apart. Weekly point-of-sale data will be collected from each community store before, during, and for six months after the six-month intervention period to measure impact on purchasing of discounted food and drinks. Data on physical, social and economic factors influencing weekly store sales will be collected in order to identify important covariates. Intervention fidelity and mediators of behaviour change will also be assessed.

Discussion
This study will provide original evidence on the effectiveness and cost-effectiveness of price discounts with or without an in-store nutrition education intervention on food and drink purchasing among a socio-economically disadvantaged population in a real-life setting.

Cost-effectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study

Background
There is broad consensus that diets high in salt are bad for health and that reducing salt intake is a cost-effective strategy for preventing chronic diseases. The World Health Organization has been supporting the development of salt reduction strategies in the Pacific Islands where salt intakes are thought to be high. However, there are no accurate measures of salt intake in these countries. The aims of this project are to establish baseline levels of salt intake in two Pacific Island countries, implement multi-pronged, cross-sectoral salt reduction programs in both, and determine the effects and cost-effectiveness of the intervention strategies.

Methods/Design
Intervention effectiveness will be assessed from cross-sectional surveys before and after population-based salt reduction interventions in Fiji and Samoa. Baseline surveys began in July 2012 and follow-up surveys will be completed by July 2015 after a 2-year intervention period.

A three-stage stratified cluster random sampling strategy will be used for the population surveys, building on existing government surveys in each country. Data on salt intake, salt levels in foods and sources of dietary salt measured at baseline will be combined with an in-depth qualitative analysis of stakeholder views to develop and implement targeted interventions to reduce salt intake.

Discussion
Salt reduction is a global priority and all Member States of the World Health Organization have agreed on a target to reduce salt intake by 30% by 2025, as part of the global action plan to reduce the burden of non-communicable diseases. The study described by this protocol will be the first to provide a robust assessment of salt intake and the impact of salt reduction interventions in the Pacific Islands. As such, it will inform the development of strategies for other Pacific Island countries and comparable low and middle-income settings around the world.

Building environmentally sustainable food systems on informed citizen choices: evidence from Australia

To address imminent concerns of global food security and agricultural sustainability, international research activities are increasingly focusing on ways of improving the food system’s efficiency and effectiveness at providing nutritious food for all in an environmentally sustainable manner. A significant component of this will involve understanding and ultimately influencing people’s dietary choices. However, for people-oriented intervention strategies to be effective, the gaps between existing behaviour and what is required for environmentally sustainable and healthy food choices must be specified. This paper identifies priority areas for behavioural change in relation to the types of food purchased, how they have been produced and the individual’s food provisioning behaviour. In order to determine the most effective ways to influence people’s consumption behaviour in light of these priority areas, the authors conducted a pilot study on a group of 163 Australians who would be expected to be ‘early adopters’ of a sustainable diet. Results show that only around 1 in 10 are presently actively engaged in reducing the environmental impact of their diets in these priority areas. Hence, there is a significant need to engage many more people in sustainable dietary behaviours. Furthermore, it was found that areas where interventions are most likely to have the largest impact, based on high cost to the environment and likelihood of citizens changing their behaviour, are reducing the amount of food waste generated in the household and lowering the amount of junk food eaten.

Influence of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: outcomes of the Supermarket Healthy Eating for Life randomized controlled trial

BACKGROUND: Fiscal strategies are increasingly considered upstream nutrition promotion measures. However, few trials have investigated the effectiveness or cost effectiveness of pricing manipulations on diet in real-world settings. OBJECTIVE: We assessed the effects on fruit, vegetable, and beverage purchasing and consumption of a 20% price-reduction intervention, a tailored skills-based behavior-change intervention, and a combined intervention compared with a control condition. DESIGN: The Supermarket Healthy Eating for Life trial was a randomized controlled trial conducted over 3 mo [baseline (time 1) to postintervention (time 2) with a 6-mo follow-up (time 3)]. Female primary household shoppers in Melbourne, Australia, were randomly assigned to a 1) skill-building (n = 160), 2) price-reduction (n = 161), 3) combined skill-building and price-reduction (n = 160), or 4) control (n = 161) group. Supermarket transaction data and surveys were used to measure the following study outcomes: fruit, vegetable, and beverage purchases and self-reported fruit and vegetable consumption at each time point. RESULTS: At 3 mo (time 2), price reduction-alone participants purchased more total vegetables and frozen vegetables than did controls. Price reduction-alone and price reduction-plus-skill-building participants purchased more fruit than did controls. Relative to controls, in the price-reduction group, total vegetable consumption increased by 233 g/wk (3.1 servings or 15% more than at baseline), and fruit purchases increased by 364 g/wk (2.4 servings; 35% more than at baseline). Increases were not maintained 6 mo postintervention (time 3). Price reduction-alone participants showed a tendency for a slight increase in fruit consumption at time 2 (P = 0.09) that was maintained at time 3 (P = 0.014). No intervention improved purchases of bottled water or low-calorie beverages. CONCLUSIONS: A 20% price reduction in fruit and vegetables resulted in increased purchasing per household of 35% for fruit and 15% for vegetables over the price-reduction period. These findings show that price modifications can directly increase produce purchases. The Supermarket Healthy Eating for Life trial was registered at Current Controlled Trials Registration as ISRCTN39432901.

Still serving hot soup? Two hundred years of a charitable food sector in Australia: a narrative review

OBJECTIVE: Despite the importance of the charitable food sector for a proportion of the Australian population, there is uncertainty about its present and future contributions to wellbeing. This paper describes its nature and examines its scope for improving health and food security. METHODS: The review, using systematic methods for public health research, identified peer-reviewed and grey literature relevant to Australian charitable food programs (2002 to 2012). RESULTS: Seventy publications met the criteria and informed this paper. The sector includes food banks, more than 3,000 community agencies and 800 school breakfast programs. It provides food for up to two million people annually. The scope extends beyond emergency food relief and includes case management, advocacy and other support. Weaknesses include a food supply that is sub-optimal, resource limitations and lack of evidence to evaluate or support their work towards food security. CONCLUSIONS: The sector supports people experiencing disadvantage and involves multiple organisations, working in a variety of settings, to provide food for up to 8% of the population. The limits on the sector's capacity to address food insecurity by itself must be acknowledged so that civil society, government and the food industry can support sufficient, nutritious and affordable food for all.

The influence on population weight gain and obesity of the macronutrient composition and energy density of the food supply

Rates of overweight and obesity have increased dramatically in all regions of the world over the last few decades. Almost all of the world's population now has ubiquitous access to low-cost, but highly-processed, energy-dense, nutrient-poor food products. These changes in the food supply, rather than decreases in physical activity, are most likely the primary driver of population weight gain and obesity. To-date, the majority of prevention efforts focus on personalised approaches targeting individuals. Population-wide food supply interventions addressing sodium and trans fat reduction have proven highly effective and comparable efforts are now required to target obesity. The evidence suggests that strategies focusing upon reducing the energy density and portion size of foods will be more effective than those targeting specific macronutrients. Government leadership, clearly specified targets, accountability and transparency will be the key to achieving the food supply changes required to address the global obesity epidemic.