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Abstract Background A voluntary National Healthy Food and Drink Policy (the Policy) was introduced in public hospitals in New Zealand in 2016. This study assessed the changes in implementation of the Policy and its impact on providing healthier food and drinks for staff and visitors in four district health boards between 1 and 5 years after the initial Policy introduction. Methods Repeat, cross-sectional audits were undertaken at the same eight sites in four district health boards between April and August 2017 and again between January and September 2021. In 2017, there were 74 retail settings audited (and 99 in 2021), comprising 27 (34 in 2021) serviced food outlets and 47 (65 in 2021) vending machines. The Policy’s traffic light criteria were used to classify 2652 items in 2017 and 3928 items in 2021. The primary outcome was alignment with the Policy guidance on the proportions of red, amber and green foods and drinks (≥ 55% green ‘healthy’ items and 0% red ‘unhealthy’ items). Results The distribution of the classification of items as red, amber and green changed from 2017 to 2021 (p

Abstract Background Dietary risk factors are the leading cause of death globally and in New Zealand (NZ). Processed packaged foods are prevalent in the food supply and contribute excess amounts of sodium, saturated fat, and sugar in diets. Improving the nutritional quality of these foods has the potential to reduce population chronic disease risk. We aimed to evaluate the healthiness using the Australasian Health Star Rating (HSR, from 0.5 to 5 stars, with 5 being the healthiest) and nutrient composition (sodium, saturated fat, and total sugar) of packaged products manufactured by the largest NZ-based food and beverage companies in NZ 2015–2019. This analysis relates to a larger study evaluating structured engagement with food companies to improve nutrition-related policies and actions. Methods Data was sourced from Nutritrack, a NZ-branded supermarket-sourced food composition database. The largest NZ-based companies from annual retail sales revenue (n = 35) were identified using 2019 Euromonitor data. All relevant products of the selected companies were extracted for analysis. Products included totalled 17,795 with a yearly range of 3462–3672 products. The primary outcome was a nutrient profile score estimated using HSR. Healthiness was defined as ≥ 3.5 stars. Secondary outcomes were sodium, total sugar, and saturated fat per 100 g/100 mL. All outcomes were assessed overall, by food company, and food category. Change over time was tested using linear mixed models, adjusting for major food categories and cluster effects of food companies controlling for multiple comparisons. Model-adjusted mean differences between years were estimated with 95% confidence intervals. Results There was a small statistically significant increase in mean HSR between 2015 and 2019 (0.08 [0.15,0.01], p = 0.024). Mean total sugar content decreased over the same period (0.78 g/100 g [0.08,1.47], p = 0.020), but there were no significant changes in mean sodium or saturated fat contents. Seven of the 13 categories showed small increases in mean HSR (0.1–0.2). Most categories (9/13) exhibited a reduction in mean total sugar content. Conclusions Between 2015 and 2019, there were slight improvements in the nutritional quality of selected packaged foods and drinks in NZ. Much more substantive changes are needed to address the health-related burden of unhealthy diets, supported by stronger government action and less reliance on voluntary industry initiatives.

Abstract Background In 2016, a voluntary National Healthy Food and Drink Policy was released to improve the healthiness of food and drinks for sale in New Zealand health sector organisations. The Policy aims to role model healthy eating and demonstrate commitment to health and well-being of hospital staff and visitors and the general public. This study aimed to understand the experiences of hospital food providers and public health dietitians/staff in implementing the Policy, and identify tools and resources needed to assist with the implementation. Methods A maximum variation purposive sampling strategy (based on a health district’s population size and food outlet type) was used to recruit participants by email. Video conference or email semi-structured interviews included 15 open-ended questions that focused on awareness, understanding of, and attitudes towards the Policy; level of support received; perceived customer response; tools and resources needed to support implementation; and unintended or unforeseen consequences. Data was analysed using a reflexive thematic analysis approach. Results Twelve participants (eight food providers and four public health dietitians/staff) were interviewed; three from small ( 300,000 people) health districts. There was agreement that hospitals should role model healthy eating for the wider community. Three themes were identified relating to the implementation of the Policy: (1) Complexities of operating food outlets under a healthy food and drink policy in public health sector settings; (2) Adoption, implementation, and monitoring of the Policy as a series of incoherent ad-hoc actions; and (3) Policy is (currently) not achieving the desired impact. Concerns about increased food waste, loss of profits and an uneven playing field between food providers were related to the voluntary nature of the unsupported Policy. Three tools could enable implementation: a digital monitoring tool, a web-based database of compliant products, and customer communication materials. Conclusions Adopting a single, mandatory Policy, provision of funding for implementation actions and supportive tools, and good communication with customers could facilitate implementation. Despite the relatively small sample size and views from only two stakeholder groups, strategies identified are relevant to policy makers, healthcare providers and public health professionals.

Abstract Background In 2016, a voluntary National Healthy Food and Drink Policy (hereafter, “the Policy”) was released to encourage public hospitals in New Zealand to provide food and drink options in line with national dietary guidelines. Five years later, eight (of 20) organisations had adopted it, with several preferring to retain or update their own institutional-level version. This study assessed staff and visitors’ awareness and support for and against the Policy, and collected feedback on perceived food environment changes since implementation of the Policy. Methods Cross-sectional electronic and paper-based survey conducted from June 2021 to August 2022. Descriptive statistics were used to present quantitative findings. Free-text responses were analysed following a general inductive approach. Qualitative and quantitative findings were compared by level of implementation of the Policy, and by ethnicity and financial security of participants. Results Data were collected from 2,526 staff and 261 visitors in 19 healthcare organisations. 80% of staff and 56% of visitors were aware of the Policy. Both staff and visitors generally supported the Policy, irrespective of whether they were aware of it or not, with most agreeing that “Hospitals should be good role models.” Among staff who opposed the Policy, the most common reason for doing so was freedom of choice. The Policy had a greater impact, positive and negative, on Māori and Pacific staff, due to more frequent purchasing onsite. Most staff noticed differences in the food and drinks available since Policy implementation. There was positive feedback about the variety of options available in some hospitals, but overall 40% of free text comments mentioned limited choice. 74% of staff reported that food and drinks were more expensive. Low-income staff/visitors and shift workers were particularly impacted by reduced choice and higher prices for healthy options. Conclusions The Policy led to notable changes in the healthiness of foods and drinks available in NZ hospitals but this was accompanied by a perception of reduced value and choice. While generally well supported, the findings indicate opportunities to improve implementation of food and drink policies (e.g. providing more healthy food choices, better engagement with staff, and keeping prices of healthy options low) and confirm that the Policy could be expanded to other public workplaces.

Abstract Objective To examine the effects of health-related food taxes on substitution and complementary purchases within food groups, including from unhealthier to healthier alternatives and between brands. Methods We used data from a virtual supermarket experiment with data from 4,259 shopping events linked to varying price sets. Substitution or complementary effects within six frequently purchased food categories were analyzed. Products’ own- and cross-price elasticities were analyzed using Almost Ideal Demand System models. Results Overall, 37.5% of cross-price elasticities were significant (p

Abstract Background Successful implementation and long-term maintenance of healthy supermarkets initiatives are crucial to achieving potential population health benefits. Understanding barriers and enablers of implementation of real-world trials will enhance wide-scale implementation. This process evaluation of a healthy supermarket intervention sought to describe (i) customer, retailer and stakeholder perspectives on the intervention; (ii) intervention implementation; and (iii) implementation barriers and enablers. Methods Eat Well @ IGA was a 12-month randomised controlled trial conducted in 11 Independent Grocers of Australia (IGA) chain supermarkets in regional Victoria, Australia (5 intervention and 6 wait-listed control stores). Intervention components included trolley and basket signage, local area and in-store promotion, and shelf tags highlighting the healthiest packaged foods. A sequential mixed-methods process evaluation was undertaken. Customer exit surveys investigated demographics, and intervention recall and perceptions. Logistic mixed-models estimated associations between customer responses and demographics, with store as random effect. Supermarket staff surveys investigated staff demographics, interactions with customers, and intervention component feedback. Semi-structured stakeholder interviews with local government, retail and academic partners explored intervention perceptions, and factors which enabled or inhibited implementation, maintenance and scalability. Interviews were inductively coded to identify key themes. Results Of 500 customers surveyed, 33%[95%CI:23,44] recalled the Eat Well @ IGA brand and 97%[95%CI:93,99] agreed that IGA should continue its efforts to encourage healthy eating. The 82 staff surveyed demonstrated very favourable intervention perceptions. Themes from 19 interviews included that business models favour sales of unhealthy foods, and that stakeholder collaboration was crucial to intervention design and implementation. Staff surveys and interviews highlighted the need to minimise staff time for project maintenance and to regularly refresh intervention materials to increase and maintain salience among customers. Conclusions This process evaluation found that interventions to promote healthy diets in supermarkets can be perceived as beneficial by retailers, customers, and government partners provided that barriers including staff time and intervention salience are addressed. Collaborative partnerships in intervention design and implementation, including retailers, governments, and academics, show potential for encouraging long-term sustainability of interventions. Trial registration ISRCTN, ISRCTN37395231 Registered 4 May 2017.

Abstract Background Institutions are a recommended setting for dietary interventions and nutrition policies as these provide an opportunity to improve health by creating healthy food environments. In Australia, state and territory governments encourage or mandate institutions in their jurisdiction to adopt nutrition policies. However, no work has analysed the policy design across settings and jurisdictions. This study aimed to compare the design and components of government-led institutional nutrition policies between Australian states and territories, determine gaps in existing policies, and assess the potential for developing stronger, more comprehensive policies. Methods Government-led institutional nutrition policies, in schools, workplaces, health facilities and other public settings, were identified by searching health and education department websites for each Australian state and territory government. This was supplemented by data from other relevant stakeholder websites and from the Food Policy Index Australia website. A framework for monitoring and evaluating nutrition policies in publicly-funded institutions was used to extract data and a qualitative analysis of the design and content of institutional nutrition policies was performed. Comparative analyses between the jurisdictions and institution types were conducted, and policies were assessed for comprehensiveness. Results Twenty-seven institutional nutrition policies were identified across eight states and territories in Australia. Most policies in health facilities and public schools were mandatory, though most workplace policies were voluntary. Twenty-four included nutrient criteria, and 22 included guidelines for catering/fundraising/advertising. While most included implementation guides or tools and additional supporting resources, less than half included tools/timelines for monitoring and evaluation. The policy design, components and nutrient criteria varied between jurisdictions and institution types, though all were based on the Australian Dietary Guidelines. Conclusions Nutrition policies in institutions present an opportunity to create healthy eating environments and improve population health in Australia. However, the design of these policies, including lack of key components such as accountability mechanisms, and jurisdictional differences, may be a barrier to implementation and prevent the policies having their intended impact.

Abstract Background The Australian federal government will soon release voluntary sodium reduction targets for 30 packaged food categories through the Healthy Food Partnership. Previous assessments of voluntary targets show variable industry engagement, and little is known about the extent that major food companies and their products contribute to dietary sodium purchases among Australian households. Methods The aim of this cross-sectional study was to identify the relative contribution that food companies and their products made to Australian household sodium purchases in 2018, and to examine differences in sodium purchases by household income level. We used 1 year of grocery purchase data from a nationally representative consumer panel of Australian households who reported their grocery purchases (the Nielsen Homescan panel), combined with database that contains product-specific sodium content for packaged foods and beverages (FoodSwitch). The top food companies and food categories were ranked according to their contribution to household sodium purchases. Differences in per capita sodium purchases by income levels were assessed by 1-factor ANOVA. All analyses were modelled to the Australian population in 2018 using sample weights. Results Sodium data were available from 7188 households who purchased 26,728 unique products and purchased just under 7.5 million food product units. Out of 1329 food companies, the top 10 accounted for 35% of unique products and contributed to 58% of all sodium purchased from packaged foods and beverages. The top three companies were grocery food retailers each contributing 12–15% of sodium purchases from sales of their private label products, particularly processed meat, cheese and bread. Out of the 67 food categories, the top 10 accounted for 73% of sodium purchased, particularly driven by purchases of processed meat (14%), bread (12%) and sauces (11%). Low-income Australian households purchased significantly more sodium from packaged products than high-income households per capita (452 mg/d, 95%CI: 363-540 mg/d, P

Abstract Background Healthy lifestyle programs that are designed specifically to appeal to and support men to improve lifestyle behaviors and lose weight are needed. The Rugby Fans in Training-New Zealand (RUFIT-NZ) program is delivered by professional rugby clubs and inspired by the successful Football Fans In Training program (FFIT), a gender sensitized weight loss program for obese middle-aged men delivered by professional football clubs in Scotland. RUFIT-NZ required development and evaluation for feasibility. Methods To develop the intervention we reviewed content from the FFIT program and evidence-based physical activity, dietary and weight management guidelines, and undertook a series of focus groups and key informant interviews. We then evaluated the feasibility of the intervention in a two-arm, parallel, pilot randomized controlled trial in New Zealand. Ninety-six participants were randomized to either the 12-week RUFIT-NZ intervention (N = 49) or a control group (N = 47). The intervention was delivered through professional rugby clubs and involved physical activity training and classroom sessions on healthy lifestyle behaviors. Pilot trial outcomes included body weight, heart rate, blood pressure, cardiorespiratory fitness, and lifestyle behaviors. Feasibility was assessed by recruitment and retention rates, and acceptability of the intervention. Results At 12 weeks the mean difference in body weight was 2.5 kg (95% CI -0.4 to 5.4), which favored the intervention. Statistically significant differences in favor of the intervention group were also observed for waist circumference, resting heart rate, diastolic blood pressure, cardiorespiratory fitness, and the proportion of participants that were adherent to 3 or more healthy lifestyle behaviors. The intervention was considered feasible to test in a full trial given the good recruitment and retention rates, and positive feedback from participants. Conclusions A pilot study of a healthy lifestyle intervention delivered via professional rugby clubs in New Zealand demonstrated positive effects on weight and physiological outcomes, as well as adherence to lifestyle behaviors. Feasibility issues in terms of recruitment, retention, and participant acceptability were assessed and findings will be used to inform the design of a definitive trial. Trial registration The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry ACTRN12616000137493, 05/12/2016.

Abstract Background The nutritional composition of foods and beverages consumed away from the home has important implications for population health. Our objective was to determine if the serve size, energy, and sodium contents of fast foods sold at chain restaurants in New Zealand (NZ) changed between 2012 and 2016. Methods Serve size and nutrient data were collected in annual cross-sectional surveys of all products sold at 10 major fast food chains. Changes over time may occur due to alterations in product availability or individual product reformulation. Linear regression adjusting for food group and chain was used to estimate overall changes in serve size and nutrients. Random effects mixed models were used to estimate reformulation changes on same products available for two or more years. Results Across all products (n = 5468) increases were observed in mean serve size (+ 9 (3, 15) g, + 5%), energy density (+ 54 (27, 81) kJ/100 g, + 6%), energy per serve (+ 178 (125, 231) kJ, + 14%), and sodium per serve (+ 55 (24, 87) mg, + 12%). Sodium density did not change significantly. Four of 12 food groups (Desserts, Pizza, Sandwiches, and Salads) and four of 10 fast food chains (Domino’s, Hell Pizza, Pizza Hut, and Subway) displayed large, undesirable changes for three or more (of five) outcomes (≥10%; p

Abstract Background The impacts of supermarket-based nutrition promotion interventions might be overestimated if participants shift their proportionate food purchasing away from their usual stores. This study quantified whether participants who received price discounts on fruits and vegetables (FV) in the Supermarket Healthy Eating for Life (SHELf) randomized controlled trial (RCT) shifted their FV purchasing into study supermarkets during the intervention period. Methods Participants were 642 females 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. Participants self-reported the proportion of FV purchased in study supermarkets at baseline, 3- and 6-months post-intervention. Fisher’s exact and χ2 tests assessed differences among groups in the proportion of FV purchased in study supermarkets at each time point. Multinomial logistic regression assessed differences among groups in the change in proportionate FV purchasing over time. Results Post-intervention, 49% of participants purchased ≥50% of their FV in study supermarkets. Compared to all other groups, the price reduction group was approximately twice as likely (RRR: 1.8-2.2) to have increased proportionate purchasing of FV in study supermarkets from baseline to post-intervention (p

Abstract Background In-store availability of healthy and unhealthy foods may influence consumer purchases. Methods used to measure food availability, however, vary widely. A simple, valid, and reliable indicator to collect comparable data on in-store food availability is needed. Methods Cumulative linear shelf length of and variety within 22 healthy and 28 unhealthy food groups, determined based on a comparison of three nutrient profiling systems, were measured in 15 New Zealand supermarkets. Inter-rater reliability was tested in one supermarket by a second researcher. The construct validity of five simple indicators of relative availability of healthy versus unhealthy foods was assessed against this ‘gold standard’. Results Cumulative linear shelf length was a more sensitive and feasible measure of food availability than variety. Four out of five shelf length ratio indicators were significantly associated with the gold standard (ρ = 0.70–0.75). Based on a non-significant difference from the ‘gold standard’ (d = 0.053 ± 0.040) and feasibility, the ratio of cumulative linear shelf length of fresh and frozen fruits and vegetables versus soft and energy drinks, crisps and snacks, sweet biscuits and confectionery performed best for use in New Zealand supermarkets. Conclusions Four out of the five shelf length ratio indicators of the relative availability of healthy versus unhealthy foods in-store tested could be used for future research and monitoring, but additional validation studies in other settings and countries are recommended. Consistent use of those shelf length ratio indicators could enhance comparability of supermarket food availability between studies, and help inform policies to create healthy consumer food retail environments.

An amendment to this paper has been published and can be accessed via the original article.

Abstract Background There is a need for accurate and precise food price elasticities (PE, change in consumer demand in response to change in price) to better inform policy on health-related food taxes and subsidies. Methods/Design The Price Experiment and Modelling (Price ExaM) study aims to: I) derive accurate and precise food PE values; II) quantify the impact of price changes on quantity and quality of discrete food group purchases and; III) model the potential health and disease impacts of a range of food taxes and subsidies. To achieve this, we will use a novel method that includes a randomised Virtual Supermarket experiment and econometric methods. Findings will be applied in simulation models to estimate population health impact (quality-adjusted life-years [QALYs]) using a multi-state life-table model. The study will consist of four sequential steps: 1. We generate 5000 price sets with random price variation for all 1412 Virtual Supermarket food and beverage products. Then we add systematic price variation for foods to simulate five taxes and subsidies: a fruit and vegetable subsidy and taxes on sugar, saturated fat, salt, and sugar-sweetened beverages. 2. Using an experimental design, 1000 adult New Zealand shoppers complete five household grocery shops in the Virtual Supermarket where they are randomly assigned to one of the 5000 price sets each time. 3. Output data (i.e., multiple observations of price configurations and purchased amounts) are used as inputs to econometric models (using Bayesian methods) to estimate accurate PE values. 4. A disease simulation model will be run with the new PE values as inputs to estimate QALYs gained and health costs saved for the five policy interventions. Discussion The Price ExaM study has the potential to enhance public health and economic disciplines by introducing internationally novel scientific methods to estimate accurate and precise food PE values. These values will be used to model the potential health and disease impacts of various food pricing policy options. Findings will inform policy on health-related food taxes and subsidies. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12616000122459 (registered 3 February 2016).

Abstract Background The Screen Time Weight-loss Intervention Targeting Children at Home (SWITCH) trial tested a family intervention to reduce screen-based sedentary behaviour in overweight children. The trial found no significant effect of the intervention on children’s screen-based sedentary behaviour. To explore these null findings, we conducted a pre-planned process evaluation, focussing on intervention delivery and uptake. Methods SWITCH was a randomised controlled trial of a 6-month family intervention to reduce screen time in overweight children aged 9–12 years (n = 251). Community workers met with each child’s primary caregiver to deliver the intervention content. Community workers underwent standard training and were monitored once by a member of the research team to assess intervention delivery. The primary caregiver implemented the intervention with their child, and self-reported intervention use at 3 and 6 months. An exploratory analysis determined whether child outcomes at 6 months varied by primary caregiver use of the intervention. Results Monitoring indicated that community workers delivered all core intervention components to primary caregivers. However, two thirds of primary caregivers reported using any intervention component “sometimes” or less frequently at both time points, suggesting that intervention uptake was poor. Additionally, analyses indicated no effect of primary caregiver intervention use on child outcomes at 6 months, suggesting the intervention itself lacked efficacy. Conclusions Poor uptake, and the efficacy of the intervention itself, may have played a role in the null findings of the SWITCH trial on health behaviour and body composition. Trial registration The trial was registered in the Australian and New Zealand Clinical Trials Registry (no. ACTRN12611000164998 ); registration date: 10/02/2011.