Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies

Objective : To examine the effects, by income group, of targeted food taxes and subsidies on nutrition, health and expenditure in the UK.

Methods : A model based on consumption data and demand elasticity was constructed to predict the effects of four food taxation-subsidy regimens. Resulting changes in demand, expenditure, nutrition, cardiovascular disease (CVD) and cancer mortality were estimated.

Data : Expenditure data were taken from the Expenditure and Food Survey; estimates of price elasticities of demand for food were taken from a report based on the National Food Survey 1988–2000. Estimates of effect on CVD and cancer mortality of changing fat, salt, fruit and vegetable intake were taken from previous meta-analyses.

Results : (i) Taxing principal sources of dietary saturated fat is unlikely to reduce cardiovascular disease (CVD) or cancer mortality. (ii) Taxing ‘less healthy’ foods (defined by the WXYfm nutrient profiling model) could increase CVD and cancer deaths by 35–1300 yearly. (iii) Taxing ‘less healthy’ foods and subsidising fruits and vegetables by 17.5% could avert up to 2900 CVD and cancer deaths yearly. (iv) Taxing ‘less healthy’ foods and using all tax revenue to subsidize fruits and vegetables could avert up to 6400 CVD and cancer deaths yearly. Few obesity-related CVD deaths are averted by any of the regimens. All four regimens would be economically regressive and positive health effects will not necessarily be greater in lower-income groups where the need for dietary improvement is higher.

Conclusions : A targeted food tax combined with the appropriate subsidy on fruits and vegetables could reduce deaths from CVD and cancer.

Breastfeeding mothers consume more vegetables and a greater variety of fruits and vegetables than non-breastfeeding peers : the influence of socioeconomic position

Aim:  This study compared the diets of breastfeeding and non-breastfeeding mothers from socioeconomically diverse regions of Melbourne to determine whether breastfeeding is a marker for healthier maternal dietary intakes.

Methods:  This cross-sectional study obtained information via self-reported questionnaire from 529 first-time Melbourne mothers. Breastfeeding status was determined when the children were 3.9 months. Diet information was obtained using a validated Food Frequency Questionnaire. Maternal diet was assessed by seven indicators: average daily intake of fruit, vegetables, non-core drinks, non-core sweet snacks, non-core savoury snacks, variety of fruit and variety of vegetables eaten in the preceding 12 months. Associations between breastfeeding status and each dietary variable were assessed using linear regression analyses. Socioeconomic position, maternal body mass index and the cluster-based sampling design were controlled for.

Results:  Of the 529 subjects, 70% were breastfeeding their child. Compared with non-breastfeeding mothers, breastfeeding mothers were found to consume more serves of vegetables (P= 0.001), a greater variety of fruit and vegetables (P= 0.001 and P≤ 0.001 respectively), and sweet snacks were consumed more frequently (P= 0.006). Differences were observed between low and high socioeconomic position mothers for fruit serves (P= 0.003), vegetable serves (P= 0.010) and fruit variety (P= 0.006). These associations persisted after controlling for socioeconomic position and maternal body mass index.

Conclusions:  The association between infant feeding (breastfeeding) and some aspects of maternal diet provides further evidence suggesting a link between maternal and child diets from a younger age than previously examined.

Children's consumption of energy dense nutrient poor foods, fruit and vegetables; are they related? An analysis of data from a cross sectional survey

Issue addressed: Many children consume excessive amounts of energy-dense, nutrient-poor (EDNP) or 'extra' foods and low intakes of fruit and vegetables. The aim of this study was to examine the associations between EDNP foods and ascertain whether certain EDNP foods and beverages are more likely to be eaten in association with other EDNP foods.

Methods: A cross-sectional representative population survey of children in preschool (n=764), and of school students in Years K, 2 and 4 (n=1,560) and in Years 6, 8 and 10 (n=1,685) residing in the Hunter New England region of New South Wales, Australia. Dietary data were collected using a short food frequency questionnaire. Multivariate logistic regression models examined the association between EDNP foods and fruit and vegetable intake. Data were stratified by sex and age cohort.

Results: More frequent consumption of some EDNP food types was significantly associated with more frequent consumption of other EDNP foods. Fast food and soft drinks consumption were associated with each other as well as with fried potato and salty snacks; and with lower intakes of fruit and vegetables in some but not all age groups.

Conclusion: The positive associations found between EDNP foods point towards the existence of a high-risk group of children who frequently consume a variety of EDNP foods and drinks.

Effect of a telephone-delivered coronary heart disease secondary prevention program (ProActive Heart) on quality of life and health behaviours: primary outcomes of a randomised controlled trial

Background Participation in coronary heart disease secondary prevention programs is low. Innovative programs to meet this treatment gap are required.

Purpose To aim of this study is to describe the effectiveness of a telephone-delivered secondary prevention program for myocardial infarction patients.

Methods Four hundred and thirty adult myocardial infarction patients in Brisbane, Australia were randomised to a 6-month secondary prevention program or usual care. Primary outcomes were health-related quality of life (Short Form-36) and physical activity (Active Australia Survey).

Results Significant intervention effects were observed for health-related quality of life on the mental component summary score (p = 0.02), and the social functioning (p = 0.04) and role-emotional (p = 0.03) subscales, compared with usual care. Intervention participants were also more likely to meet recommended levels of physical activity (p = 0.02), body mass index (p = 0.05), vegetable intake (p = 0.04) and alcohol consumption (p = 0.05).

Conclusions Telephone-delivered secondary prevention programs can significantly improve health outcomes and could meet the treatment gap for myocardial infarction patients.

Factors influencing participant enrolment in a diabetes prevention program in general practice: lessons from the Sydney diabetes prevention program

Background: The effectiveness of lifestyle interventions in reducing diabetes incidence has been well established. Little is known, however, about factors influencing the reach of diabetes prevention programs. This study examines the predictors of enrolment in the Sydney Diabetes Prevention Program (SDPP), a community-based diabetes prevention program conducted in general practice, New South Wales, Australia from 2008–2011.

Methods: SDPP was an effectiveness trial. Participating general practitioners (GPs) from three Divisions of General Practice invited individuals aged 50–65 years without known diabetes to complete the Australian Type 2 Diabetes Risk Assessment tool. Individuals at high risk of diabetes were invited to participate in a lifestyle modification program. A multivariate model using generalized estimating equations to control for clustering of enrolment outcomes by GPs was used to examine independent predictors of enrolment in the program. Predictors included age, gender, indigenous status, region of birth, socio-economic status, family history of diabetes, history of high glucose, use of anti-hypertensive medication, smoking status, fruit and vegetable intake, physical activity level and waist measurement.

Results: Of the 1821 eligible people identified as high risk, one third chose not to enrol in the lifestyle program. In multivariant analysis, physically inactive individuals (OR: 1.48, P = 0.004) and those with a family history of diabetes (OR: 1.67, P = 0.000) and history of high blood glucose levels (OR: 1.48, P = 0.001) were significantly more likely to enrol in the program. However, high risk individuals who smoked (OR: 0.52, P = 0.000), were born in a country with high diabetes risk (OR: 0.52, P = 0.000), were taking blood pressure lowering medications (OR: 0.80, P = 0.040) and consumed little fruit and vegetables (OR: 0.76, P = 0.047) were significantly less likely to take up the program.

Conclusions: Targeted strategies are likely to be needed to engage groups such as smokers and high risk ethnic groups. Further research is required to better understand factors influencing enrolment in diabetes prevention programs in the primary health care setting, both at the GP and individual level.

The stability of weight status through the early to middle childhood years in Australia: a longitudinal study

OBJECTIVES: To investigate the sociodemographic and behavioural factors associated with incidence, persistence or remission of obesity in a longitudinal sample of Australian children aged 4-10 years. SETTING: Nationally representative Longitudinal Study of Australian Children (LSAC). PARTICIPANTS: The sample for this analysis included all children in the Kinder cohort (aged 4-5 years at wave 1) who participated in all four waves of LSAC (wave 1, 2004, aged 4-5 years; wave 2, 2006, aged 6-7 years; wave 3, 2008, aged 8-9 years and wave 4, 2010, aged 10-11 years). Of the 4983 children who participated in the baseline (wave 1) survey, 4169 (83.7%) children completed all four waves of data collection. PRIMARY AND SECONDARY OUTCOME MEASURES: Movement of children between weight status categories over time and individual-level predictors of weight status change (sociodemographic characteristics, selected dietary and activity behaviours). RESULTS: The study found tracking of weight status across this period of childhood. There was an inverse association observed between socioeconomic position and persistence of overweight/obesity. Sugar-sweetened beverages and fruit and vegetable intake and screen time appeared to be important predictors of stronger tracking. CONCLUSIONS: Overweight and obesity established early in childhood tracks strongly to the middle childhood years in Australia, particularly among children of lower socioeconomic position and children participating in some unhealthy behaviour patterns.

A path model of psychosocial and health behaviour change predictors of excessive gestational weight gain

This study aimed to evaluate a conceptual model of psychosocial, behaviour change, and behavioural predictors of excessive gestational weight gain (GWG). Background: Excessive GWG can place women and their babies at risk of poor health outcomes, including obesity. Models of psychosocial and behaviour change predictors of excessive GWG have not been extensively explored; understanding the mechanisms leading to excess GWG will provide crucial evidence towards the development of effective interventions. Method: Two hundred and eighty-eight pregnant women (≤18 weeks gestation) were recruited to a prospective study. Demographic, psychosocial, health behaviour change, and behavioural factors were assessed at 17 (Time 1, T1) and 33 weeks (Time 2, T2) gestation. Pre-pregnancy and final pregnancy weight were obtained and women were classified with/without excessive GWG. Logistic regressions refined the list of predictors of excessive GWG; variables with p < .1 were included in a path analysis. Results: Age, family income, T2 depression, T2 pregnancy-specific coping, T1 buttocks dissatisfaction, T2 GWG-specific self-efficacy, T1 dietary readiness, T1 dietary importance, and T1 vegetable intake predicted excessive GWG in the logistic regressions and were included in the path model. The baseline path model demonstrated poor fit. Once statistically and theoretically plausible paths were added, adequate model fit was achieved (χ² = 21.61(9), p < .05; RMSEA = .07; CFI = .93); this revised model explained 19.5% of the variance in excessive GWG. Women with high T1 buttocks dissatisfaction were more likely to exhibit low levels of dietary readiness. Women with low dietary readiness were more likely to have a lower vegetable intake, which predicted excessive GWG. Women with higher T2 depressive symptoms were more likely to report lower GWG self-efficacy and gain excessively. Conclusion: Future behavioural GWG trials should consider combining psychosocial and health behaviour change factors to optimise GWG.

Is there scope for community health nurses to address lifestyle risk factors? The community nursing SNAP trial

Background
This paper examines the opportunity and need for lifestyle interventions for patients attending generalist community nursing services in Australia. This will help determine the scope for risk factor management within community health care by generalist community nurses (GCNs).

Methods
This was a quasi-experimental study conducted in four generalist community nursing services in NSW, Australia. Prior to service contacts, clients were offered a computer-assisted telephone interview to collect baseline data on socio-demographics, health conditions, smoking status, physical activity levels, alcohol consumption, height and weight, fruit and vegetable intake and 'readiness-to-change' for lifestyle risk factors.

Results
804 clients participated (a response rate of 34.1%). Participants had higher rates of obesity (40.5% vs 32.1%) and higher prevalence of multiple risk factors (40.4% vs 29.5%) than in the general population. Few with a SNAPW (S moking-N utrition-A lcohol-P hysical-Activity-Weight) risk factor had received advice or referral in the previous 3 months. The proportion of clients identified as at risk and who were open to change (i.e. contemplative, in preparation or in action phase) were 65.0% for obese/overweight; 73.8% for smokers; 48.2% for individuals with high alcohol intake; 83.5% for the physically inactive and 59.0% for those with poor nutrition.

Conclusions
There was high prevalence of lifestyle risk factors. Although most were ready to change, few clients recalled having received any recent lifestyle advice. This suggests that there is considerable scope for intervention by GCNs. The results of this trial will shed light on how best to implement the lifestyle risk factor management in routine practice.

Eight month post program completion: change in risk factors for chronic disease amongst participants in a four-month pedometer workplace health program

Objective: To evaluate whether participation in a 4-month, pedometer-based, physical activity, workplace health program is associated with long-term sustained improvements in risk factors for type 2 diabetesand cardiovascular disease, 8 months after the completion of the program.Design and Methods: A sample size of 720 was required. 762 Australian adults employed in primarily sedentary occupations and voluntarily enrolled in a workplace program were recruited. Demographic, behavioral, anthropometric and biomedical measurements were completed at baseline, 4 and 12 months.Results: About 76% of participants returned at 12 months. Sustained improvements at 12 months were observed for self-reported vegetable intake, self-reported sitting time and independently measured bloodpressure. Modest improvements from baseline in self-reported physical activity and independently measured waist circumference at 12 months indicated that the significant improvements observed immediately after the health program could not be sustained. Approximately half of those not meetingguidelines for physical activity, waist circumference and blood pressure at baseline, were meeting guidelines at 12 months.Conclusions: Participation in this 4-month, pedometer-based, physical activity, workplace health program was associated with sustained improvements in chronic disease risk factors at 12 months. These results indicate that such programs can have a long-term benefit and thus a potential role to play in population prevention of chronic disease.

Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol

BACKGROUND: Cardiac rehabilitation (CR) is a secondary prevention program that offers education and support to assist patients with coronary heart disease (CHD) make lifestyle changes. Despite the benefits of CR, attendance at centre-based sessions remains low. Mobile technology (mHealth) has potential to reach more patients by delivering CR directly to mobile phones, thus providing an alternative to centre-based CR. The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours (for example, physically active, fruit and vegetable intake, not smoking, low alcohol consumption) over and above usual CR services in New Zealand adults diagnosed with CHD.

METHODS/DESIGN: A two-arm, parallel, randomised controlled trial will be conducted at two Auckland hospitals in New Zealand. One hundred twenty participants will be randomised to receive a 24-week evidence- and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone (control). The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months, measured using a composite health behaviour score. Secondary outcomes include overall cardiovascular disease risk, body composition, illness perceptions, self-efficacy, hospital anxiety/depression and medication adherence.

DISCUSSION: This study is one of the first to examine an mHealth-delivered comprehensive CR program. Strengths of the trial include quality research design and in-depth description of the intervention to aid replication. If effective, the trial has potential to augment standard CR practices and to be used as a model for other disease prevention or self-management programs.

Risk of cardiovascular disease and diabetes in a working population with sedentary occupations

OBJECTIVE: To assess the prevalence of risk factors and risk for cardiovascular disease and Type 2 diabetes in employees with sedentary occupations enrolled in a workplace health-promotion program. METHODS: Participants (n = 762) were recruited from ten Melbourne workplaces, participating in a physical activity program. Demographic, behavioral, biomedical, and physical measurements were collected. RESULTS: The majority of employees were not meeting recommended guidelines for physical activity (62%), fruit intake (70%), vegetable intake (86%), body mass index (58%), or waist circumference (53%). Most had intermediate (53%) or high (7%) risk of developing Type 2 diabetes. CONCLUSIONS: The majority of Australian adults in sedentary occupations were not meeting guidelines for a number of chronic disease risk factors and a substantial proportion were unaware of their increased risk. This study supports the potential of chronic disease risk factor detection and intervention programs in the workplace.

Impact of a pedometer-based workplace health program on cardiovascular and diabetes risk profile

OBJECTIVE: To evaluate whether participation in a four-month, pedometer-based, physical activity, workplace health programme results in an improvement in risk factors for diabetes and cardiovascular disease. METHODS: Adults employed within Australia in primarily sedentary occupations and voluntarily enrolled in a workplace programme, the Global Corporate Challenge®, aimed at increasing physical activity were recruited. Data included demographic, behavioural, anthropometric and biomedical measurements. Measures were compared between baseline and four-months. RESULTS: 762 participants were recruited in April/May 2008 with 79% returning. Improvements between baseline and four-months amongst programme participants were observed for physical activity (an increase of 6.5% in the proportion meeting guidelines, OR(95%CI): 1.7(1.1, 2.5)), fruit intake (4%, OR: 1.7(1.0, 3.0)), vegetable intake (2%, OR: 1.3(1.0, 1.8)), sitting time (-0.6(-0.9, -0.3) hours/day), blood pressure (systolic: -1.8(-3.1, -.05) mmHg; diastolic: -1.8(-2.4, -1.3) mmHg) and waist circumference (-1.6(-2.4, -0.7) cm). In contrast, an increase was found for fasting total cholesterol (0.3(0.1, 0.4) mmol/L) and triglycerides (0.1(0.0, 0.1) mmol/L). CONCLUSION: Completion of this four-month, pedometer-based, physical activity, workplace programme was associated with improvements in behavioural and anthropometric risk factors for diabetes and cardiovascular disease. Long-term evaluation is required to evaluate the potential of such programmes to prevent the onset of chronic disease.

Feasibility of conducting a randomized trial to promote healthy eating, active play and sustainability awareness in early childhood curricula

We sought to evaluate the feasibility of conducting a randomized trial to evaluate the efficacy of a preschool/kindergarten curriculum intervention designed to increase 4-year-old children's knowledge of healthy eating, active play and the sustainability consequences of their food and toy choices. Ninety intervention and 65 control parent/child dyads were recruited. We assessed the study feasibility by examining recruitment and participation, completion of data collection, realization of the intervention and early childhood educators’ experiences of implementing the study protocol; our findings suggest the intervention was feasible to deliver. In addition, children's sustainability awareness of non-compostable and recyclable items increased. Children in the intervention group significantly reduced their sugary drink consumption and increased their vegetable intake at follow-up compared to control. We conclude with recommendations for revisions to the child interview and parent questionnaire delivery to ensure the roll out of the randomized trial is conducted efficiently and rigorously.

Two important exceptions to the relationship between energy density and fat content: food with reduced-fat claims and high-fat vegetable-based dishes

Objective: To test the hypothesis that many foods with reduced-fat (RF) claims are relatively energy-dense and that high-fat (HF) vegetable-based dishes are relatively energy-dilute.

Design: Nutrient data were collected from available foods in Melbourne supermarkets that had an RF claim and a full-fat (FF) equivalent. Nutrient analyses were also conducted on recipes for HF vegetable-based dishes that had more than 30% energy from fat but less than 10% from saturated fat. The dietary intake data (beverages removed) from the 1995 National Nutrition Survey were used for the reference relationships between energy density (ED) and percentage energy as fat and carbohydrate and percentage of water by weight.

Statistics: Linear regression modelled relationships of macronutrients and ED. Paired t-tests compared observed and predicted reductions in the ED of RF foods compared with FF equivalents.

Results: Both FF and RF foods were more energy-dense than the Australian diet and the HF vegetable-based dishes were less energy-dense. The Australian diet showed significant relationships with ED, which were positive for percentage energy as fat and negative for percentage energy as carbohydrate. There were no such relationships for the products with RF claims or for the HF vegetable-based dishes.

Conclusion: While, overall, a reduced-fat diet is relatively energy-dilute and is likely to protect against weight gain, there appear to be two important exceptions. A high intake of products with RF claims could lead to a relatively energy-dense diet and thus promote weight gain. Alternatively, a high intake of vegetable-based foods, even with substantial added fat, could reduce ED and protect against weight gain.

Maternal self-efficacy regarding children's eating and sedentary behaviours in the early years : Associations with children's food intake and sedentary behaviours

Introduction. This cross-sectional study aimed to describe parents' views regarding self-efficacy to influence children's eating and sedentary behaviours at two time points in early childhood, and to examine associations between these views and children's eating and sedentary behaviours.

Methods. Mothers of 1-year (n=60) and 5-year-old children (n=80) were recruited through Maternal and Child Health Centres and kindergartens in Victoria, Australia. Mothers reported children's dietary intake, television viewing and perceptions of their self-efficacy regarding children's eating and sedentary behaviours.

Results. Overall, 5-year-old children consumed significantly more energy-dense food and drink and spent significantly more time viewing TV/DVD and video. Mothers of 1-year-olds were significantly more likely to report they felt confident to limit child's consumption of non-core foods/drinks, and to limit screen access (p<0.001). Measures of maternal self-efficacy were directly associated with 5-year-old children's water (p<0.05), and fruit and vegetable consumption (p<0.005), and with 1-year-old children's vegetable consumption (p<0.05), and were inversely associated with cordial and cake consumption (p<0.05). Maternal self-efficacy to limit viewing time was inversely associated with screen-time exposure in both age groups (p<0.01).

Conclusion. This study suggests that mother's self-efficacy regarding limiting non-core foods/drinks and limiting screen-time exposures may decline during the first few years of a child's life. Higher maternal self-efficacy was associated with children having more obesity protective eating and sedentary behaviours at both ages. Interventions to support the development of healthy lifestyle behaviours may be most effective if they target mothers' self-efficacy in these domains early in their child's life.