Milkfat characteristics and functionality: opportunities for improvement

Manipulation of the composition of milkfat has the potential to improve the nutritional properties and physical functionality of milkfat and its acceptability in the market. The modifications that have been targeted from a nutritional perspective have included:
(a) reducing the ratio of saturated to unsaturated fatty acids;
(b) increasing the level of omega-3 polyunsaturated fatty acids; and
(c) increasing the content of conjugated linoleic acid.
From a physical functionality viewpoint, the outcome targeted has been an improvement in the spreadability of butter by altering milkfat composition to reduce the hardness of milkfat. Both on-farm strategies and the application of appropriate post-farm processing technologies may be used to alter the milkfat composition to enhance its nutritional image and its physical functionality for a range of product applications. However, changes in milkfat composition that are desirable for a specific nutritional purpose or for one type of milk-based product may not meet all the desirable requirements of another milkfat or dairy product. Furthermore, modification of the milkfat composition can also have an influence on the processing characteristics of milk and the quality of finished dairy products. It is essential to substantiate the benefits of specific target nutritional or physical functionality outcomes before the introduction of breeding goals, altered milk production systems or post-farm processing operations to manipulate milkfat composition. This paper reviews the variation in milkfat characteristics and the strategies that have been used to modify milkfat composition to achieve milkfat with altered nutritional and physical functional properties.

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder

Objective: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]).

Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filters ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs).

Results: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater.

Conclusions: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

Assessing cost-effectiveness in mental health : vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia.

Method: The net benefit of IPS is assessed from a health sector perspective using cost–benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis.

Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M–$A13.6M), the benefits are $A4.7M ($A3.1M–$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M–$A3.4M).

Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

A comparison of self-reported puberty using the pubertal development scale and the sexual maturation scale in a school-based epidemiologic survey

Purpose: To examine concordance between two self-reported measures of puberty: Sexual Maturatiom Scale (SMS) and Pubertal Developl1!ent Scale (PDS) and their acceptability to adolescents. Methods: Participants of a school-based study in grades 5, 7 and 9 were classified into one of 5 pubertal stages using each method. Results: 2864 students (age 9-16 years) participated. Agreement was moderate for males (K 0.42, 95% CI 0.39,0.45) and females (K 0.57, 95% CI 0.53, 0.61). Concordance within one stage was excellent (females 97%, males 89%), with discrepancies due to females being classified one stage later on the PDS (26%) and males one stage earlier (32%). There were more missing data for the SMS (13%) than the PDS (4%).

Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

Results: Replacing oral typicals with risperidone or olanzapine has an incremental costeffectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least costeffective intervention is to replace risperidone with olanzapine at A$160 000/DALY.

Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents

Objective:
To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MDD) in children and adolescents, compared to ‘current practice’.
Method:
The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria (‘equity’; ‘strength of evidence’, ‘feasibility’ and ‘acceptability to stakeholders’) is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MDD arising in eligible children (age 6–17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios.
Results:
Compared to current practice, CBT by public psychologists is the most costeffective intervention for MDD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders.
Conclusions:
Cognitive behavioural therapy provided by a public psychologist is the most
effective and cost-effective option for the first-line treatment of MDD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require ‘start-up’ costs and attention to ensuring an adequate workforce.

Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

Objective: To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice.

Method: Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental costeffectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted.

Results: The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient.

Conclusions: MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

Biometric, nutritional and organoleptic changes in intensively farmed Murray Cod (Maccullochella peelii peelii) purged for different time periods

A period of purging before harvesting is common practice in intensive aquaculture to eliminate any possible off flavours from the fish. The present study was conducted to evaluate the biometrical, nutritional and sensory changes in intensively farmed Murray cod (Maccullochella peelii peelii) after 0, 2 and 4 weeks of purging. After the main biometric parameters were recorded, fish were analysed for proximate, fatty acid composition and flavour volatile compounds. A consumer preference test (triangle test) was also conducted to identify sensorial differences that may affect the consumer acceptability of the product.

Fish purged for 2 and 4 weeks had a significant weight loss of 4.1% and 9.1%, respectively, compared to unpurged fish, whilst perivisceral fat content did not change. The concentration of saturated (SFA), monounsaturated (MUFA) and highly unsaturated (HUFA) fatty acids were not significantly affected by purging time, while polyunsaturated fatty acids (PUFA), n − 3 and n − 3 HUFA were significantly higher (P < 0.05) in purged fish compared to unpurged fish. Consumers were able to detect differences between the purged and unpurged fish (P < 0.05) preferring the taste of the purged fish. However, consumers were unable to distinguish between fish purged for 2 and 4 weeks.

This study showed that a 2 weeks purging period was necessary and sufficient to ameliorate the final organoleptic quality of farmed Murray cod. With such a strategy the nutritional qualities of edible flesh are improved while the unavoidable body weight loss is limited.

Functional extruded snack products based on chickpea (Cicer arietinum L.) and fenugreek (Trigonella foenum-graecum) flours

Background – Chickpea and fenugreek are both legumes that confer several nutritional and functional virtues, especially to diabetes and associated metabolic syndrome conditions. They are high in protein and fibre, low in fat and prove to be low glycaemic. They also provide a gluten-free alternative to those suffering from celiac disease. Though these seeds are locally available, hardly any products appear on the supermarket shelves.
Objectives – The aim was to utilise the health and nutritional benefits of chickpea and fenugreek and develop acceptable snack products by extrusion technology.
Design – Preliminary trials were conducted with different proportions of rice and chickpea at a range of extruder conditions to optimise the raw material and processing conditions. Studies were then conducted at optimum processing conditions using a 7:3 chickpea and rice combination replacing with 2% fenugreek or 5, 10, 15 and 20% FenuLifeÒ (deodorized fenugreek powder). Products were evaluated for their physical (expansion, crunchiness and colour) and sensory ( texture, colour, flavour and overall acceptability) characteristics in order to identify their suitability as snack products.
Outcomes – Addition of chickpea up to 70% with rice showed increased expansion and stable product characteristics. Addition of fenugreek and FenuLifeÒ, indicated slight reduction in product expansion (radial) and crunchiness. However, the product made with 20% FenuLifeÒ had significant changes in expansion, crunchiness and colour values. The median scores of sensory evaluation indicated that all products were within the acceptable range. Inclusion of fenugreek showed lower ratings for flavour due to the strong bitter taste of fenugreek. There were no significant differences between products containing FenuLifeÒ (5-15%) in their colour, flavour, texture and overall quality.
Conclusion – This study demonstrates an opportunity for using chickpea and fenugreek in functional product development. Fenugreek in the form of deodorize powder (fenulifeÒ) could be incorporated up to 15% in a mixture of chickpea and rice to develop snack products of acceptable physical and sensory properties.

Biometric, nutritional and sensory changes in intensively farmed Murray cod (Maccullochella peelii peelii, Mitchell) following different purging times

A period of purging before harvesting is common practice in intensive aquaculture to eliminate any possible off flavours from the fish. The present study was conducted to evaluate the biometrical, nutritional and sensory changes in intensively farmed Murray cod (Maccullochella peelii peelii) after 0, 2 and 4 weeks of purging. After the main biometric parameters were recorded, fish were analysed for proximate, fatty acid composition and flavour volatile compounds. A consumer preference test (triangle test) was also conducted to identify sensorial differences that may affect the consumer acceptability of the product.

Fish purged for 2 and 4 weeks had a significant weight loss of 4.1% and 9.1%, respectively, compared to unpurged fish, whilst perivisceral fat content did not change. The concentration of saturated (SFA), monounsaturated (MUFA) and highly unsaturated (HUFA) fatty acids were not significantly affected by purging time, while polyunsaturated fatty acids (PUFA), n − 3 and n − 3 HUFA were significantly higher (P < 0.05) in purged fish compared to unpurged fish. Consumers were able to detect differences between the purged and unpurged fish (P < 0.05) preferring the taste of the purged fish. However, consumers were unable to distinguish between fish purged for 2 and 4 weeks.

This study showed that a 2 weeks purging period was necessary and sufficient to ameliorate the final organoleptic quality of farmed Murray cod. With such a strategy the nutritional qualities of edible flesh are improved while the unavoidable body weight loss is limited.

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective
 To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.
Method
A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.
Results
The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).
Conclusion
Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

Use of a decision aid for prenatal testing of fetal abnormalities to improve women's informed decision making: a cluster randomised controlled trial [ISRCTN22532458]

Objective To evaluate the effectiveness of a decision aid for prenatal testing of fetal abnormalities compared with a pamphlet in supporting women's decision making.
Design A cluster randomised controlled trial.
Setting Primary health care.
Population Women in early pregnancy consulting a GP.
Methods GPs were randomised to provide women with either a decision aid or a pamphlet. The decision aid was a 24-page booklet designed using the Ottowa Decision Framework. The pamphlet was an existing resource available in the trial setting.
Main outcome measures Validated scales were used to measure the primary outcomes, informed choice and decisional conflict, and the secondary outcomes, anxiety, depression, attitudes to the pregnancy/fetus and acceptability of the resource. Outcomes were measured at 14 weeks of gestation from questionnaires that women completed and returned by post.
Findings Women in the intervention group were more likely to make an informed decision 76% (126/165) than those in the control group 65% (107/165) (adjusted OR 2.08; 95% CI 1.14–3.81). A greater proportion of women in the intervention group 88% (147/167) had a 'good' level of knowledge than those in the control group 72% (123/171) (adjusted OR 3.43; 95% CI 1.79–6.58). Mean (SD) decisional conflict scores were low in both groups, decision aid 1.71 (0.49), pamphlet 1.65 (0.55) (adjusted mean difference 0.10; 95% CI −0.02 to 0.22). There was no strong evidence of differences between the trial arms in the measures of psychological or acceptability outcomes.
Conclusion A tailored prenatal testing decision aid plays an important role in improving women's knowledge of first and second trimester screening tests and assisting them to make decisions about screening and diagnostic tests that are consistent with their values.

Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs

Objective: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR.

Design: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team.

Setting: Six regional hospitals in south-west Victoria offering hospital-based CR programs.

Participants: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs.

Main outcomes measures: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery.

Results: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook.

Conclusions: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.

Developing a stakeholder analysis to aid bio-based product innovation

Purpose – The results which that study seeks to report are the first part of a larger research programme funded by the New Zealand Foundation for Research, Science & Technology (FRST) aimed at gaining a better understanding of stakeholder perceptions in relation to bio-based products.

Design/methodology/approach – Utilising three chemically modified wood products, data were collected from focus groups and questionnaires and centred primarily on perceptions surrounding the acceptability of building materials that have been bio-modified. Irrespective of the type of chemical modification, family health and durability were the most important factors identified.

Findings – The study finds that product cost rated lower in the 16 factors evaluated, and energy used in production was of little concern. When comparing the three products to one another, two distinct groups with quite differing purchasing philosophies were identified and these perspectives significantly influenced perceptions of product acceptability and willingness to purchase. Utilising a paired comparison technique, an investigation of trade-offs indicated preference for performance over cost and product familiarity. Similarly, low chemical emissions were also preferred over cost considerations. Among the findings, there was scepticism regarding trust in manufacturers to adequately safeguard health and safety and to have a minimum impact on the environment. Low levels of trust were expressed in regard to manufacturers' concern for future generations.

Originality/value – The paper develops an investigative framework which could be applied to the evaluation of products arising from bio-material technology innovation and recommendations for future research directions.

Chemical modification of timber decking: looking to the future

To help avoid conflict and even market rejection, the design and introduction of new technologies can be aided by consideration of the potential concerns of different stakeholder groups. An assessment of their desired goals for technological change may be useful for pre-empting changes in the  parameters of acceptability for technologies. As part of a research  programme evaluating the parameters of acceptability for bio-based  technologies using life cycle assessment of products and an analysis of the  perceptual frameworks of stakeholders, respondents from four stakeholder  groups in New Zealand were interviewed about the desirable and  undesirable trajectories for chemical modification technologies. Three  examples of pine decking products derived using different amounts and  types of chemical modification served to help explore the contemporary  criteria and rationale for acceptability. The responses of the 70 respondents  in those four groups indicated that new technologies need to be able to  prove their worth with regard to both tangible and intangible qualities if they  are to be accepted into the market in the place of either the existing product  or an inorganic competitor.