Australasian nutrition research for prevention and management of child obesity : innovation and progress in the last decade

The Food and Nutrition stream of Australasian Child and Adolescent Obesity Research Network (ACAORN) aims to improve the quality of dietary methodologies and the reporting of dietary intake within Australasian child obesity research (http://www.acaorn.org.au/streams/nutrition/). With 2012 marking ACAORN’s 10th anniversary, this commentary profiles a selection of child obesity nutrition research published over the last decade by Food and Nutrition Stream members. In addition, stream activities have included the development of an online selection guide to assist researchers in their selection of appropriate dietary intake methodologies (http://www.acaorn.org.au/streams/nutrition/dietary-intake/index.php). The quantity and quality of research to guide effective child obesity prevention and treatment has increased substantially over the last decade. ACAORN provides a successful case study of how research networks can provide a collegial atmosphere to foster and co-ordinate research efforts in an otherwise competitive environment.

The influence of food literacy on the everyday practicalities of meeting nutrition recommendations

Contemporary nutrition policies and plans call for focussing efforts to improve nutrition through a closer connection with food and the everyday practicalities of how people live and eat. Various words have been used to articulate what this might mean in practice. More recently, the term “food literacy” has emerged to explain this gap between the policy aims the (in)ability of people to know, understand and use food to meet nutrition recommendations. Despite its increasing use, there is no common understanding of this term or its components. Once established, food literacy could be measured in order to examine its association with nutritional outcomes. A Delphi study of 43 Australian food experts from diverse sectors and settings explored their understanding of the term “food literacy”, the likely components and possible relationship with nutrition. The three round Delphi study began with a semi-structured telephone interview and was followed by two online surveys. Constructivist grounded theory was used to analyse data, from which a conceptual model of the relationship between food literacy and nutrition was developed. The model was then tested and refined following a phenomenological study of 37 young people aged 16-25 years who were responsible for feeding themselves. They were interviewed about their food intake, day-to-day food decision making, the knowledge and skills used and their perceptions of someone who is “good with food”. Analysis from the Delphi study identified, eighty components of food literacy and these were grouped into eight domains: 1)access, 2)planning and management, 3)selection, 4)knowing where food comes from, 5)preparation, 6)eating, 7)nutrition and 8)food related language. When these were compared to results of the Young People’s study it was found that while specific components of food literacy were largely contextual, the importance of all eight domains continued to be relevant. The results of these qualitative studies have set the boundaries and scope of meaning of food literacy and will be used to inform the development of measurable variables to be tested in a quantitative cross-sectional study. This prospective study will examine the relationship between food literacy and nutrition. This research is useful in guiding government strategy and investment, and informing the planning, implementation and evaluation of interventions by practitioners.

Nutrition screening and assessment in Parkinson's disease : a comparison of methods

Background & Aims Nutrition screening and assessment enable early identification of malnourished people and those at risk of malnutrition. Appropriate assessment tools assist with informing and monitoring nutrition interventions. Tool choice needs to be appropriate to the population and setting. Methods Community-dwelling people with Parkinson’s disease (>18 years) were recruited. Body mass index (BMI) was calculated from weight and height. Participants were classified as underweight according to World Health Organisation (WHO) (≤18.5kg/m2) and age specific (<65 years,≤18.5kg/m2; ≥65 years,≤23.5kg/m2) cut-offs. The Mini-Nutritional Assessment (MNA) screening (MNA-SF) and total assessment scores were calculated. The Patient-Generated Subjective Global Assessment (PG-SGA), including the Subjective Global Assessment (SGA), was performed. Sensitivity, specificity, positive predictive value, negative predictive value and weighted kappa statistic of each of the above compared to SGA were determined. Results Median age of the 125 participants was 70.0(35-92) years. Age-specific BMI (Sn 68.4%, Sp 84.0%) performed better than WHO (Sn 15.8%, Sp 99.1%) categories. MNA-SF performed better (Sn 94.7%, Sp 78.3%) than both BMI categorisations for screening purposes. MNA had higher specificity but lower sensitivity than PG-SGA (MNA Sn 84.2%, Sp 87.7%; PG-SGA Sn 100.0%, Sp 69.8%). Conclusions BMI lacks sensitivity to identify malnourished people with Parkinson’s disease and should be used with caution. The MNA-SF may be a better screening tool in people with Parkinson’s disease. The PG-SGA performed well and may assist with informing and monitoring nutrition interventions. Further research should be conducted to validate screening and assessment tools in Parkinson’s disease.  

Linking food literacy to nutrition

“Food literacy” is an emerging term used to describe the relative ability to understand the nature of food and how it is important. It also describes the ability to gather, process, analyse and act upon information about food and to apply it in individual settings. A Delphi study of 43 Australian food experts from diverse sectors and settings in all states and territories explored the meaning of food literacy, its constitutive components and how they relate to nutrition. The three-round Delphi began with a semi-structured telephone interview and was followed by two online surveys. Grounded theory was used to develop a conceptual model of the relationship between food literacy and nutrition. It is proposed that food literacy influences nutrition through three related mechanisms of security, choice and pleasure. These mechanisms will be mediated by the local food supply and individual values. The relative importance of components of food literacy will depend upon these mediators. The level of nutrition outcome being sought (for example, dietary guidelines versus food group serves) will also influence the relative importance of these components. This model will be useful in informing program planning and evaluation and will be tested and refined following a phenomenological study of consumers.

Animal stories : flash flood 2011

Flash flood disasters happen suddenly. The Toowoomba Lockyer Valley flash flood in January 2011 was not forecast by the Bureau of Meteorology until after it had occurred. Domestic and wild animals gave the first warning of the disaster in the days leading up to the event and large animals gave warnings on the morning of the disaster. Twenty-three people, including 5 children in the disaster zone died. More than 500 people were listed as missing. Some of those who died, perished because they stayed in the disaster zone to look after their animals while other members of their family escaped to safety. Some people who were in danger refused to be rescued because they could not take their pets with them. During a year spent recording accounts of the survivors of the disaster, animals were often mentioned by survivors. Despite the obvious perils, people risked their lives to save their animals; people saw animals try to save each other; animals rescued people; people rescued animals; animals survived where people died; animals were used to find human victims in the weeks after the disaster; and animals died. The stories of the flood present challenges for pet owners, farmers, counter disaster planners, weather forecasters and emergency responders in preparing for disasters, responding to them and recovering after them.

A novel, automated nutrition screening system as a predictor of nutritional risk in an oncology day treatment unit (ODTU)

Purpose Paper-based nutrition screening tools can be challenging to implement in the ambulatory oncology setting. The aim of this study was to determine the validity of the Malnutrition Screening Tool (MST) and a novel, automated nutrition screening system compared to a ‘gold standard’ full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA). Methods An observational, cross-sectional study was conducted in an outpatient oncology day treatment unit (ODTU) within an Australian tertiary health service. Eligibility criteria were as follows: ≥18 years, receiving outpatient anticancer treatment and English literate. Patients self-administered the MST. A dietitian assessed nutritional status using the PGSGA, blinded to the MST score. Automated screening system data were extracted from an electronic oncology prescribing system. This system used weight loss over 3 to 6 weeks prior to the most recent weight record or age-categorised body mass index (BMI) to identify nutritional risk. Sensitivity and specificity against PG-SGA (malnutrition) were calculated using contingency tables and receiver operating curves. Results There were a total of 300 oncology outpatients (51.7 % male, 58.6±13.3 years). The area under the curve (AUC) for weight loss alone was 0.69 with a cut-off value of ≥1 % weight loss yielding 63 % sensitivity and 76.7 % specificity. MST (score ≥2) resulted in 70.6 % sensitivity and 69.5 % specificity, AUC 0.77. Conclusions Both the MST and the automated method fell short of the accepted professional standard for sensitivity (~≥80 %) derived from the PG-SGA. Further investigation into other automated nutrition screening options and the most appropriate parameters available electronically is warranted to support targeted service provision.

Improving the performance of nutrition screening through a series of quality improvement initiatives

Background Nutrition screening identifies patients at risk of malnutrition to facilitate early nutritional intervention. Studies have reported incompletion and error rates of 30-90% for a range of commonly used screening tools. This study aims to investigate the incompletion and error rates of 3-Minute Nutrition Screening (3-MinNS) and the effect of quality improvement initiatives in improving the overall performance of the screening tool and the referral process for at risk patients. Methods Annual audits were carried out from 2008-2013 on 4467 patients. Value Stream Mapping, Plan-Do-Check-Act cycle and Root Cause Analysis were used in this study to identify gaps and determine the best intervention. The intervention included 1) implementing a nutrition screening protocol, 2) nutrition screening training, 3) nurse empowerment for online dietetics referral of at-risk cases, 4) closed-loop feedback system and 5) removing a component of 3-MinNS that caused the most error without compromising its sensitivity and specificity. Results Nutrition screening error rates were 33% and 31%, with 5% and 8% blank or missing forms, in 2008 and 2009 respectively. For patients at risk of malnutrition, referral to dietetics took up to 7.5 days, with 10% not referred at all. After intervention, the latter decreased to 7% (2010), 4% (2011) and 3% (2012 and 2013), and the mean turnaround time from screening to referral was reduced significantly from 4.3 ± 1.8 days to 0.3 ± 0.4 days (p < 0.001). Error rates were reduced to 25% (2010), 15% (2011), 7% (2012) and 5% (2013) and percentage of blank or missing forms reduced to and remained at 1%. Conclusion Quality improvement initiatives are effective in reducing the incompletion and error rates of nutrition screening, and led to sustainable improvements in the referral process of patients at nutritional risk.

Sports dietitians Australia position statement : sports nutrition for the adolescent athlete

It is the position of Sports Dietitians Australia (SDA) that adolescent athletes have unique nutritional requirements as a consequence of undertaking daily training and competition in addition to the demands of growth and development. As such, SDA established an expert multidisciplinary panel to undertake an independent review of the relevant scientific evidence and consulted with its professional members to develop sports nutrition recommendations for active and competitive adolescent athletes. The position of SDA is that dietary education and recommendations for these adolescent athletes should reinforce eating for long term health. More specifically, the adolescent athlete should be encouraged to moderate eating patterns to reflect daily exercise demands and provide a regular spread of high quality carbohydrate and protein sources over the day, especially in the period immediately after training. SDA recommends that consideration also be given to the dietary calcium, Vitamin D and iron intake of adolescent athletes due to the elevated risk of deficiency of these nutrients. In order to maintain optimal hydration, adolescent athletes should have access to fluids that are clean, cool and supplied in sufficient quantities before, during and after participation in sport. Finally, it is the position of SDA that use of nutrient needs should be met by core foods rather than supplements, as the recommendation of dietary supplements to developing athletes over-emphasises their ability to manipulate performance in comparison to other training and dietary strategies.

Pushing cultural competence boundaries in nutrition and dietetics training

A health workforce ready for safe practice is a government priority, and particularly critical to support indigenous communities closing ‘the gap’. Increased pressure exists on dietetic training programs for quality placements, with fewer opportunities for immersion in Aboriginal and Torres Strait Islander communities to demonstrate cultural competence. In 2012, Queensland University of Technology established a partnership with Apunipima Cape York Health Council with 56 weeks of dietetic placement for 8 students provided to achieve these aims. Clinical practice in Community Public Health Nutrition (CPHN) was structured in a standard 6 week placement, with Individual Case Management (ICM) and Foodservice Management (FSM) integrated across 8 weeks (4 each), with an additional 2 weeks ICM prior in a metropolitan indigenous health service. Students transitioned from urban to rural then remote sites, with new web-based technologies used for support. Strong learning opportunities were provided, with CPHN projects in antenatal and child health, FSM on standardisation of procedures in a 22 bed health facility, and ICM exposing students to a variety of cases via hospital in/outpatients, general clinics and remote community outreach. Supervisor focus group evaluation was positive, with CPHN and FSM enhancing capacity of service. Student focus group evaluation revealed placements exceeded expectations, with rating high, and strong confidence in cultural competence described. Students debriefed final and third year cohorts on their experiences, with increased awareness and enthusiasm for work with indigenous communities indicated by groups. With the success of this partnership, placements are continuing 2013, and new boundaries in dietetic training established.

Socioeconomic differences in food choices : deficiencies in nutrition knowledge or simply too much on your plate?

Nutrition knowledge is associated with dietary choices in the general population and has been proposed to contribute to socioeconomic differences in food choices and corresponding socioeconomic gradients in mortality and morbidity for a number of diet-related illnesses. This paper explores current evidence regarding socioeconomic differences in nutrition knowledge, reviewing the components of nutrition knowledge that have been assessed, the dietary intake or food choice outcomes considered, and the socioeconomic indicators used. In addition, this paper considers how socioeconomic differences in nutrition knowledge may arise, and potential determinants of inequalities in the application of nutrition knowledge. It highlights issues to consider when developing strategies to improve nutrition knowledge and facilitate knowledge application among those of lower socioeconomic position.

An assessment of the geographical scale of recurrent gene flow in wild populations of two species of Mekong River carps (Henicorhynchus spp.)

The Mekong is the most productive river fishery in the world, and such as, the Mekong River Basin (MRB) is very important to very large human populations across the region as a source of revenue (through fishing and marketing of aquatic resources products) and as the major source for local animal protein. Threats to biodiversity in the MRB, either to the fishery sector itself or to other sectors are a major concern, even though currently, fisheries across this region are still very productive. If not managed properly however, fish population declines will cause significant economic impact and affect livelihoods of local people and will have a major impact on food security and nutrition. Biodiversity declines will undoubtedly affect food security, income and socio-economic status of people in the MRB that depend on aquatic resources. This is an indicator of unsustainable development and hence should be avoided. Genetic diversity (biodiversity) that can be measured using techniques based on DNA markers; refers to variation within and among populations within the same species or reproductive units. In a population, new genetic variation is generated by sexual recombination contributed by individuals with mutations in genes and chromosomes. Over time, populations of a species that are not reproducing together will diverge as differential impacts of selection and genetic drift change their genetic attributes. For mud carp (Henicorhynchus spp.), understanding the status of breeding units in the MRB will be important for their long term persistence, sustainability and for implementing effective management strategies. Earlier analysis of stock structure in two economically important mud carp species (Henicorhynchus siamensis and H. lobatus) in the MRB completed with mtDNA markers identified a number of populations of both species where gene flow had apparently been interrupted or reduced but applying these data directly to management unit identification is potentially compromised because information was only available about female dispersal patterns. The current study aimed to address this problem and to fully assess the extent of current gene flow (nDNA) and reproductive exchange among selected wild populations of two species of carp (Henicorhynchus spp.) of high economic importance in the MRB using combined mtDNA and nDNA markers. In combination, the data can be used to define effective management units for each species. In general, nDNA diversity for H. lobatus (with average allelic richness (A) 7.56 and average heterozygosity (Ho) 0.61) was very similar to that identified for H. siamensis (A = 6.81 and Ho = 0.75). Both mud carp species show significant but low FST estimates among populations as a result of lower genetic diversity among sampled populations compared with genetic diversity within populations that may potentially mask any 'real' population structure. Overall, population genetic structure patterns from mtDNA and nDNA in both Henicorhynchus species were largely congruent. Different population structures however, were identified for the two Henicorhynchus species across the same geographical area. Apparent co-similarity in morphology and co-distribution of these two relatively closely related species does not apparently imply parallel evolutionary histories. Differences in each species population structure likely reflect historical drainage rearrangement of the Mekong River. The data indicate that H. siamensis is likely to have occupied the Mekong system for much longer than has H. lobatus in the past. Two divergent stocks were identified for H. lobatus in the MRB below the Khone Falls while a single stock had been evident in the earlier mtDNA study. This suggests that the two Henicorhynchus species may possess different life history traits and that different patterns of gene flow has likely influenced modern genetic structure in these close congeners. In combination, results of the earlier mtDNA and the current study have implications for effective management of both Henicorhynchus species across the MRB. Currently, both species are essentially treated as a single management unit in this region. This strategy may be appropriate for H. lobatus as a single stock was evident in the main stream of the MRB, but may not be appropriate for H. siamensis as more than a single stock was identified across the same range for this species. Management strategies should consider this difference to conserve overall biodiversity (local discrete populations) and this will include maintaining natural habitat and migration pathways, provision of fish sanctuaries (refuges) and may also require close monitoring of any stock declines, a signal that may require effective recovery strategies.

Nutrition and physical activity policies and practices in family child care homes

Background Family child care homes (FCCHs) are the second-largest provider of nonrelative care in the U.S. However, despite providing care for nearly 1.9 million children aged <5 years, little is known about the nutrition and physical activity practices of FCCHs. Purpose To address this gap, this study aims to describe policies and practices related to nutrition and physical activity in a representative sample of FCCHs. Methods A stratified random sample of registered FCCHs operating in Kansas (N=297) completed the Nutrition and Physical Activity Self Assessment for Child Care (NAPSACC) instrument. Prevalence estimates and 95% CIs for meeting or exceeding accepted child care standards were calculated using SAS PROC SURVEYFREQ. Results Most providers either met or exceeded child care standards related to serving fruit and vegetables and provision of daily physical activity. Very few providers reported serving fried meats or vegetables or unhealthy snack foods on a regular basis. Areas of concern included infrequent servings of low-fat milk, frequent use of unhealthy foods for celebrations, widespread use of TV and video games throughout the day, restricting physical activity for children who misbehave, and lack of appropriate indoor spaces for physical activity. Only a small percentage of providers reported receiving regular training in nutrition or physical activity. Relatively few providers had written guidelines on nutrition or physical activity. Conclusions Some strengths were exhibited by FCCHs, but substantial weaknesses were shown with respect to meeting established child care standards for nutrition and physical activity. Interventions to promote healthy eating and regular physical activity in FCCHs are thus warranted.

A nutrition and physical activity intervention for family child care homes

Background Family child care homes (FCCHs) provide child care to 1.9 million children in the U.S., but many do not meet established child care standards for healthy eating and physical activity. Purpose To determine the effects of a community-based train-the-trainer intervention on FCCHs policies and practices related to healthy eating and physical activity. Design Quasi-experimental design with replication in three independent cohorts of FCCHs. Setting/participants Registered FCCHs from 15 counties across Kansas participated in the Healthy Kansas Kids (HKK) program. Resource and referral agencies (RRAs) in each county recruited and enrolled between five and 15 child care providers in their service delivery area to participate in the program. The number of registered FCCHs participating in HKK in Years 1 (2006-2007); 2 (2007-2008); and 3 (2008-2009) of the program were 85, 64, and 87, respectively. A stratified random sample of registered FCCHs operating in Kansas (n=297) served as a normative comparison group. Interventions Child care trainers from each RRA completed a series of train-the-trainer workshops related to promotion of healthy eating and physical activity. FCCHs were subsequently guided through a four-step iterative process consisting of (1) self-evaluation; (2) goal setting; (3) developing an action plan; and (4) evaluating progress toward meeting goals. FCCHs also received U. S. Department of Agriculture resources related to healthy eating and physical activity. Main outcome measures Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) self-assessment instrument (NAP SACC-SA). Analyses of outcome measures were conducted between 2008 and 2010. Results Healthy Kansas Kids FCCHs exhibited significant improvements in healthy eating (Delta=6.9%-7.1%) and physical activity (Delta=15.4%-19.2%) scores (p<0.05). Within each cohort, pre-intervention scores were not significantly different from the state average, whereas post-intervention scores were significantly higher than the state average. Conclusions Community-based train-the-trainer interventions to promote healthy eating and physical activity in FCCHs are feasible, sustainable, and effective.

Community interventions to promote proper nutrition and physical activity among youth

In recent years a compelling body of knowledge has been accumulated to support the belief that physical activity and dietary behaviors carry important health consequences for young people. It has long been known that adequate nutrition and physical activity are essential for normal growth and development [1]. Recently, however, clear evidence has emerged that diet and physical activity during childhood and adolescence also affect an array of physiological factors associated with risk for developing chronic diseases; these factors include body composition (e.g., adiposity), blood lipid concentrations, blood pressure, and bone mineral density It also appears that physical activity and dietary behaviors and the physiological outcomes associated with them often track from childhood and adolescence into adulthood. Thus, risky health behaviors adopted early in life may negatively influence health in adulthood by having both a short-term effect on physiological risk factors and a long-term impact on health behavior.

Nutrition and physical activity policies and practices in family child care homes in oregon : baseline findings from the healthy home child care project

Baseline findings from the Healthy Home Child Care Project include data from Family Child Care Providers (FCCPs) in Oregon (n=53) who completed assessments of nutrition and physical activity policies and practices and BMI data for children in the care of FCCPs (n=205). Results show that a significant percentage of FCCPs failed to meet child care standards in several areas and that 26.8% of children under the care of FCCPs were overweight or obese. These data supported the development of an Extension-delivered intervention specific to FCCPs in Oregon and highlight areas of concern that should be addressed through targeted trainings of FCCPs.