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Using group model building we developed a series of causal loop diagrams identifying the environmental impacts of ultra-processed food (UPF) systems, and underlying system drivers, which was subsequently validated against the peer-reviewed literature. The final conceptual model displays the commercial, biological and social drivers of the UPF system, and the impacts on environmental sub-systems including climate, land, water and waste. It displays complex interactions between various environmental impacts, demonstrating how changes to one component of the system could have flow-on effects on other components. Trade-offs and uncertainties are discussed. The model has a wide range of applications including informing the design of quantitative analyses, identifying research gaps and potential policy trade-offs resulting from a reduction of ultra-processed food production and consumption.

Objective:The choice of terms used to describe ‘foods to limit’ (FTL) in food-based dietary guidelines (FBDG) can impact public understanding, policy translation and research applicability. The choice of terms in FBDG has been influenced by available science, values, beliefs and historical events. This study aimed to analyse the terms used and definitions given to FTL in FBDG around the world, including changes over time and regional differences.Design:A review of terms used to describe FTL and their definitions in all current and past FBDG for adults was conducted, using a search strategy informed by the FAO FBDG website. Data from 148 guidelines (96 countries) were extracted into a pre-defined table and terms were organised by the categories ‘nutrient-based’, ‘food examples’ or ‘processing-related’.Setting:National FBDG from all world regions.Participants:None.Results:Nutrient-based terms (e.g. high-fat foods) were the most frequently used type of term in both current and past dietary guidelines (91 %, 85 %, respectively). However, food examples (e.g. cakes) and processing-related terms (e.g. ultra-processed foods) have increased in use over the past 20 years and are now often used in conjunction with nutrient-based terms. Regional differences were only observed for processing-related terms.Conclusion:Diverse, and often poorly defined, terms are used to describe FTL in FBDG. Policymakers should ensure that FTL terms have clear definitions and can be integrated with other disciplines and understood by consumers. This may facilitate the inclusion of the most contemporary and potentially impactful terminology in nutrition research and policies.

Dietary change is often presented as a key factor in the transition toward healthy sustainable diets. However, the evidence base is limited as most studies are based on a single environmental aspect, such as climate impact, contrived dietary scenarios that don't reflect the full array of foods typically eaten, or dietary patterns that are not nutritionally adequate. In this study, a weighted environmental impact (EI) score was developed using a planetary boundary-based distance-to-target approach. The included environmental aspects were climate footprint, water-scarcity footprint, and cropland-scarcity footprint. To enable sensitivity analysis, three alternative weighting models were also developed. The EI scores were calculated for a large number of processed and unprocessed foods in the Australian food system and used to assess 9,341 individual Australian adult daily diets obtained from the Australian Health Survey. A diet quality score, assessing the level of compliance with the food based Australian Dietary Guidelines, was also applied. For the current average diet, energy-dense and nutrient-poor discretionary foods made the largest contribution to the total EI score. Moderating the intake of these foods should be a priority in strategies seeking to promote healthy sustainable diets. Using quadrant analysis, a dietary pattern with a lower EI score was identified that achieved the Australian Dietary Guidelines, however the reduction in EI score was modest, at around 15%, and insufficient to achieve planetary boundary targets. Notably, gains in climate impact reduction were achieved at the expense of increases in water-scarcity footprint, highlighting the trade-offs between different objectives. To achieve healthy diets within planetary boundaries in Australia, the greater share of impact reduction may need to occur in the food production system.

Background Overconsumption of energy-dense, nutrient-poor “discretionary” foods and beverages can indicate poor diet quality, which is a risk factor for obesity and chronic disease. With 60% of Australians exceeding the recommended intake of discretionary foods, there is a need for interventions to reduce their consumption. Objective The objective was to model the impact of 26 specific scenarios to limit discretionary food intake on energy and nutrient intake. Design The scenario modeling analysis was based on reduction strategies targeting portion size, frequency, or variety of discretionary food and beverage items consumed. Participants/Setting Data from 12,153 respondents aged 2 to 85 years from the 2011-12 Australian National Nutrition and Physical Activity Survey were used. Outcome measures The outcome measures were change in servings of discretionary foods and key nutrients (energy, total fat, saturated fat, sugar, alcohol, sodium, trans fat) for the population, and by sex, age group, weight status, and socioeconomic status. Statistical analyses performed Descriptive and inferential statistical analysis were conducted. Results Scenarios reduced total energy intake by up to 26% across the population as a whole. The removal of discretionary foods (not beverages) resulted in the greatest reduction in servings and energy (74.8% and 25.6%, respectively), followed by the removal of discretionary items in portions greater than 143 kcal (59.1% and 24.3%) and not consuming discretionary items at main meals (51.2% and 17.8%). Targeting single categories of discretionary foods reduced energy intake by an average of 5.6% for the removal of cakes and biscuits, 4.4% for alcohol, and 3.9% for sugar-sweetened beverages. Strategies reduced total fat, saturated fat, and sugar by up to 35%, 38%, and 40% respectively. Conclusions Strategies that are specific to discretionary food and beverage intake targeting reductions in portion size, frequency, or variety have the potential to reduce energy intake and improve diet quality. These findings have implications for designing interventions with potential to tailor messages to current dietary habits. Exploration of how these strategies could be effectively implemented will be the focus of further research.

BACKGROUND Engagement is key to interventions achieving successful behavior change and improvements in health. There is scarce evidence in the literature on applying predictive machine learning (ML) models to data from commercially available weight loss programs to predict disengagement. Such data could help in supporting participants to achieve their goals. OBJECTIVE This study aimed to use explainable machine learning to predict member risk of disengagement over each of the 12 weeks on a commercially available online weight loss program. METHODS Data were available from 59,686 adults who joined the commercial weight loss program between October 2014 and September 2019. Data included year of birth, sex, height, weight, motivation for joining the program, usage statistics (e.g., weight entries, entries into the food diary, views of the menu, and program content), program type and weight loss. Random forest (RF), boosted trees (XGB) and logistic regression (LR) with regularization l1 (L1) models were developed and validated with a 10-fold cross-validation approach. In addition, temporal validation was performed on a test cohort of 16,947 members who participated in the program between April 2018 and September 2019, while the remainder of the data was used for model development. Shapley values were used to identify globally relevant features and explain individual predictions. RESULTS The average age of participants was 49.60 (SD 12.54) years, the average starting BMI was 32.43 (SD 6.19) and 81.5% of participants were females. Class distributions (active/inactive members) changed from 39,369/9,235 in week 2 to 31,602/17,002 in week 12. With 10-fold-cross-validation, XGB models had the best predictive performance which ranged from 0.85 (95%CI 0.84 0.85) to 0.93 (95%CI 0.93 0.93) for ROC AUC and from 0.57 (95%CI 0.56 0.58) to 0.95 (95%CI 0.95 0.96) for AUC PRC across 12 weeks of the program. They also presented good calibration. Results obtained with temporal validation ranged from 0.51 to 0.95 for AUC PRC and 0.84 to 0.93 for ROC AUC across the 12 weeks. There was a considerable improvement in AUC PRC of 20% in week 3 of the program. Based on computed Shapley values, the most important features for predicting disengagement in the following week were those related to total activity on the platform and entering a weight in the previous weeks. CONCLUSIONS This study showed the potential of applying ML predictive algorithms to help to understand participants’ disengagement with an online weight loss program. Given the association between engagement and health outcomes, these findings will be useful to better support individuals to achieve greater engagement and potentially weight loss on the 12-week program.

The purpose of this study was to investigate changes in the range and nutrient profile of processed alternative protein “convenience” products available in Australia from 2014 to 2021. Product data were extracted from FoodTrack™, an established database of packaged supermarket products. Eligible products were grouped into subcategories: (i) tofu products; (ii) legume products; and (iii) plant-based meats. Nutrient composition was assessed from the products’ nutrition information panel. The number of alternative protein products in supermarkets more than doubled between 2014 and 2021 (+130%). On average, products were available for 2.2 years (range 1–7 years). Generally, tofu products had the highest contents of saturated fat and sodium, legume products had the highest contents of carbohydrates, sugar and fibre, and plant-based meats had the highest contents of protein and total fat (per 100 g). This study found large variation in the nutrient composition of these products, highlighting the importance of reformulation and consumer education in the future.

Objective:Agriculture accounts for around 70 % of global freshwater withdrawals. As such, the food system has been identified as a critical intervention point to address water scarcity. Various studies have identified dietary patterns that contribute less to water scarcity. However, it is unclear what level of reduction is necessary to be considered sustainable. The pursuit of unnecessarily aggressive reductions could limit dietary diversity. Our objective was to assess the sustainability of water use supporting Australian dietary habits and the adequacy of current dietary guidelines.Design:Dietary intake data were obtained from the National Nutrition and Physical Activity component of the Australian Health Survey. For each individual daily diet, the water scarcity footprint was quantified, following ISO14046:2014, as well as a diet quality score. Water scarcity footprint results were compared with the planetary boundary for freshwater use downscaled to the level of an individual diet.Setting:Australia.Participants:9341 adults participating in the Australian Health Survey.Results:Dietary water scarcity footprints averaged 432·6 L-eq (95 % CI 432·5, 432·8), less than the 695 litres/person per d available to support the current global population of 7·8 billion, and the 603 litres/person per d available for a future population of 9 billion. Diets based on the Australian Dietary Guidelines required 521 L-eq/d, or 379 L-eq/d with lower water scarcity footprint food choices.Conclusions:Diets based on the Australian Dietary Guidelines were found to be within the freshwater planetary boundary. What is needed in Australia is greater compliance with dietary guidelines.

Objectives:Consumption is driven by children’s sensory acceptance, but little is known about the sensory characteristics of vegetables that children commonly eat. A greater understanding could help design more effective interventions to help raise intakes, thus realising beneficial health effects. This study sought to: (1) Understand the vegetable consumption patterns in children, with and without potatoes, using the Australian and WHO definitions. (2) Describe the sensory characteristics of vegetables consumed by children by age group, level of intake and variety. (3) Determine the vegetable preferences of children, by age group, level of intake and variety.Design:Analysis of National Nutrition Survey data, combining reported vegetable intake with sensory characteristics described by a trained panel.Setting:AustraliaParticipants:A nationally representative sample of Australian children and adolescents aged 2–17·9 years (n 2812).Results:While consumption increased in older age groups, variety remained constant. Greater variety, however, was associated with higher vegetable consumption. Potato intake increased with consumption, contributing over one-third of total vegetable intake for highest vegetable consumption and for older age groups. Children favoured relatively sweet vegetables and reported lower consumption of bitter vegetables. There were no differences in the sensory properties of vegetables consumed by children in different age groups. After potatoes, carrots, sweetcorn, mixtures, fruiting and cruciferous types were preferred vegetables.Conclusion:Children tend to prefer vegetables with sensory characteristics consistent with innate taste preferences (sweet and low bitterness). Increasing exposure to a variety of vegetables may help increase the persistently low vegetable consumption patterns of children.

Avocados are a rich source of unsaturated fats and bioactives, however, their role in altering cardiometabolic risk factors is unclear.To review the effects of consuming diets containing avocado compared to control diets containing no or low amounts of avocado on cardiometabolic risk factors in adults who were healthy, had clinical CVD or were at increased risk of CVD.Five electronic databases were searched (PubMed, Web of Science, Scopus, ProQuest and a Clinical Trials Registry) along with Google Scholar to identify studies published between January 1990 and November 10, 2021. Randomised controlled trials (RCT) ≥ 3 weeks and prospective cohort studies were included. Ten studies, nine RCTs (n=503 participants) and one prospective observational study (n=55,407), met the inclusion criteria. Outcomes assessed by meta-analysis were: LDL-C (primary), total cholesterol (TC), HDL-C and triglycerides. Outcomes assessed by narrative review were: TC to HDL-C ratio, non-HDL-C, apolipoprotein B, blood pressure, body weight, BMI, waist circumference, waist-to-hip ratio, body composition, blood glucose and insulin concentrations. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool and Newcastle-Ottawa Scale, and quality of evidence examined using the GRADE method. Random-effects models meta-analyses were performed where there was ≥ 3 studies of the same design (i.e. RCT) and reporting the same outcome. Statistical heterogeneity was assessed by calculating ChiOverall there was a small, significant reduction in TC (-5.08 mg/dL (-9.29, -0.87 mg/dL), p = 0.02) in avocado vs. control groups and no significant difference in LDL-C, HDL-C or triglycerides. Subgroup analysis demonstrated significant reductions in LDL-C (-9.4 mg/dl (-10.84, -7.95 mg/dL) p0.00001) and TC (-7.54 mg/dL (-9.40, -5.68 mg/dL), p0.00001) in avocado vs. control groups in hypercholesterolaemic populations while no differences were seen in normocholesterolaemic populations. However, the certainty in the findings was graded as low to very low. Body weight and composition were not negatively affected by avocado consumption.Avocado consumption may reduce TC and LDL-C in people with hypercholesterolaemia. Avocado consumption does not negatively impact body weight. Larger, well-conducted studies are needed to have greater confidence in the role of avocado consumption on CVD risk factors.

Objective:To examine core and discretionary food and beverage intake at eating occasions, and to explore the variation in consumption by age and gender in Australian adults and children.Design:The study utilised one 24-h dietary recall with self-reported eating occasions from a nationally representative sample of Australians. Average servings of each food group for age and gender subpopulations were compared with the Australian Dietary Guidelines. The percentage contribution of each eating occasion to total daily food group intake and typical composition of eating occasions were described. Frequently consumed discretionary foods were reported for eating occasions by age and gender.Setting:2011–2012 Australian National Nutrition and Physical Activity Survey.Participants:12 153 Australian people aged 2 years and above.Results:Grains were consumed in equal proportions throughout the day across all age and gender subgroups, while remaining core food groups were unequally distributed, featuring more prominently at specific eating occasions. Children consumed two-thirds of their fruit intake as snacks, and up to three quarters of adults’ vegetable and meat intake was consumed at dinner. Children consumed more of their discretionary intake at mid-meals, while adults consumed a greater proportion as part of a main meal.Conclusions:The present study provides a detailed understanding about when food groups are consumed, the ‘typical’ meal composition across the day, and how consumption patterns and compliance with dietary guidelines differ by age group and gender. These findings can assist in developing more specific nutrition messages which may help to achieve greater improvements in population dietary intake.

There is conflicting advice about the inclusion of dairy foods in a lower greenhouse gas (GHG) emission dietary pattern. Our purpose was to assess the prevalence of dairy food intake among higher diet quality and lower GHG emission diets in Australia and within these diets assess the association between level of dairy food intake and adequate intake of a broad range of nutrients. Dietary intake data collected using a 24-h recall process were sourced from the most recent Australian Health Survey. Diet quality was assessed by level of compliance with the food group-based Australian Dietary Guidelines. A subgroup of 1732 adult (19 years and above) daily diets was identified having higher diet quality score and lower GHG emissions (HQLE). Intake of core dairy foods (milk, cheese, yoghurt) was assessed and nutrient profiling was undertaken for 42 macro- and micronutrients. The HQLE subgroup had 37% higher diet quality score and 43% lower GHG emissions than the average Australian adult diet (P

Objective: Diet-related self-identity, which includes components such as individuals’ overall dietary pattern and food choice motivations, is a strong predictor of health behaviors. This study sought to assess the variation in dietary patterns reported by a sample of Australian adults and their associations with diet quality. Design: Cross-sectional survey. Participants: Australian adults (n = 2,010) Variables measured: The main outcome measure was diet quality relative to the Australian Dietary Guidelines, measured by the Healthy Diet Score survey. Other outcomes captured included dietary patterns(eg, unrestricted, vegetarian, flexitarian, or ketogenic diets), diet-related self-identity constructs (centrality, prosocial motivation, personal motivation, and strictness), and sociodemographic characteristics (eg, age, sex, and education level). Analysis: Data were analyzed descriptively, and ordinary least squares regression was performed to identify significant predictors of diet quality. Results: Eighteen unique dietary patterns were reported. These were classified into 3 categories on the basis of the degree of restriction of core food groups. Diets based on restriction of animal protein were associated with the highest diet quality, including the highest consumption of fruits, vegetables, and wholegrains, whereas restriction of other foods was associated with the poorest diet quality. Unrestricted diets reported the highest consumption of discretionary food (high in saturated fat, salt, or added sugar). Finally, the regression analysis found that diet quality was significantly predicted by dietary pattern and diet-related self-identity constructs (F[8, 1974] = 54.952; P < 0.0001; adjusted R2 = 0.179).Conclusions and Implications: Dietary pattern and diet-related self-identity constructs are key determinants of diet quality. This has implications for future interventions, including that programs and messages could be tailored to ensure they align with the target population’s self-identity and overall dietary patterns. Refereed/Peer-reviewed

Food-based dietary guidelines (FBDGs) provide country-specific guidance on what constitutes a healthy diet. With increasing evidence for the synergy between human and planetary health, FBDGs have started to consider the environmental sustainability of food choices. However, the number of countries that discuss environmental sustainability in their guidelines is unknown. The purpose of this Review was to identify countries with government-endorsed FBDGs that made explicit mention of environmental sustainability and to examine the breadth and depth of the inclusion of sustainability in FBDGs. The Food and Agriculture Organization of the UN identified 95 countries with FBDGs. We assessed 83 countries against our inclusion criteria, of which 37 mentioned environmental sustainability. Relevant content was assessed against a set of criteria based on the Food and Agriculture Organization's guiding principles for sustainable healthy diets. The depth to which environmental sustainability was discussed varied and it was often restricted to general explanations of what a sustainable diet is. Few FBDGs addressed why sustainability is important, how dietary changes can be made, or provided quantified advice for implementing sustainable diets.

Pesticides are widely used in food production, yet the potential harm associated with their emission into the environment is rarely considered in the context of sustainable diets. In this study, a life cycle assessment was used to quantify the freshwater ecotoxicity, human toxicity carcinogenic effects, and human toxicity noncarcinogenic effects associated with pesticide use in relation to 9341 individual Australian adult daily diets. The three environmental indicators were also combined into a pesticide toxicity footprint, and a diet quality score was applied to each diet. Energy-dense and nutrient-poor discretionary foods, fruits, and protein-rich foods were the sources of most of the dietary pesticide impacts. Problematically, a dietary shift toward recommended diets was found to increase the pesticide toxicity footprint compared to the current average diet. Using a quadrant analysis, a recommended diet was identified with a 38% lower pesticide toxicity footprint. This was achieved mainly through a reduction in the discretionary food intake and by limiting the choice of fresh fruits. As the latter contradicts dietary recommendations to eat a variety of fruits of different types and colors, we concluded that dietary change may not be the best approach to lowering the environmental impacts of pesticides in the food system. Instead, targeted action in the horticultural industry may be more effective. Consumers might encourage this transition by supporting growers that reduce pesticide use and apply less environmentally harmful active ingredients.

Aim To assess dietary intake and nutritional adequacy amongst self-identified symptomatic wheat-avoiders. Methods Thirty-four self-identified symptomatic avoiders of wheat-based products without a diagnosis of coeliac disease or wheat allergy were recruited to participate in a dietary assessment study. Dietary intake was assessed via a three-day weighed food record. Participants were aged 33 to 83 years, were predominantly women (n = 30) and had been avoiding wheat for a mean of six years. Nutrient intakes were compared with Nutrient Reference Values. Food group intakes were assessed and consumption of wheat-containing and wheat-free cereal-based foods described. Results Inadequate intakes of key protective nutrients such as fibre and calcium were common; many participants reported avoiding dairy as well as wheat. Intakes of total and saturated fat exceeded recommendations. Although 85% of the sample reported avoiding all wheat products, at least one third of cereal products and dishes consumed in this group, comprising mostly discretionary-type foods, were wheat based. Conclusions Dietary intake patterns and resulting nutrient imbalances in individuals restricting or eliminating wheat to manage symptoms are cause for concern. The situation is likely exacerbated by the tendency for many wheat avoiders to report also avoiding other foods, especially dairy products. A bi-disciplinary approach from medical practitioners and dietitians to individuals experiencing unexplained gastro-intestinal symptoms and strategies to support informed food choice is needed to combat longer-term health consequences of a diet with this nutritional profile.

Background Obesity is a global public health challenge, and there is a need for more evidence-based self-management programs that support longer-term, sustained weight loss. Objective This study used data from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Total Wellbeing Diet Online program to determine the reach and weight loss results over its first 5 years. Methods Participants were adults who joined the commercial weight loss program of their own volition between October 2014 and September 2019 (N=61,164). Information collected included year of birth, sex, height, weight, and usage data (eg, entries into the food diary, views of the menu, and program content). Weight loss and percentage of starting body weight lost were calculated. Members were divided into 2 groups for analysis: “stayers” were members who signed up for at least 12 weeks of the program and recorded a weight entry at baseline and at the end of the program, while “starters” began the program but did not record a weight after 12 weeks. Descriptive statistics and multiple linear regression were used to describe weight loss and determine the member and program characteristics associated with weight loss. Results Data were available from 59,686 members for analysis. Members were predominately female (48,979/59,686, 82.06%) with an average age of 50 years (SD 12.6). The average starting weight was 90.2 kg (SD 19.7), and over half of all members (34,195/59,688, 57.29%) were classified as obese. At week 12, 94.56% (56,438/59,686) of the members had a paid program membership, which decreased to 41.48% (24,756/59,686) at 24 weeks. At week 12, 52.03% (29,115/55,958) of the remaining members were actively using the platform, and by week 24, 26.59% (14,880/55,958) were using the platform. The average weight loss for all members was 2.8 kg or 3.1% of their starting body weight. Stayers lost 4.9 kg (5.3% of starting body weight) compared to starters, who lost 1.6 kg (1.7% of starting body weight). Almost half (11,082/22,658, 48.91%) the members who stayed on the program lost 5% or more of their starting body weight, and 15.48% (3507/22,658) achieved a weight loss of 10% or more. Of the members who were classified as class 1 obese when they joined the program, 41.39% (3065/7405) who stayed on the program were no longer classified as obese at the end, and across all categories of obesity, 24% (3180/13,319) were no longer classified as obese at the end of the program. Based on multiple linear regression, platform usage was the strongest predictor of weight loss (β=.263; P Conclusions This comprehensive evaluation of a commercial, online weight loss program showed that it was effective for weight loss, particularly for members who finished the program and were active in using the platform and tools provided. If the results demonstrated here can be achieved at an even greater scale, the potential social and economic benefits will be extremely significant.

Globally, population dietary intakes fall below the guideline recommendations and large-scale interventions have had modest success in improving diet quality. To inform the development of more targeted approaches, this study analysed the variations in self-reported data from an online survey of Australian adults collected between 2015 and 2020, to identify common combinations of low scoring components within a dietary guideline index. A low score was defined as meeting less than half the guideline recommendations (a score &lt, 50 out of 100). Among 230,575 adults, a single component analysis showed that 79.5% had a low score for discretionary choices, 72.2% for healthy fats and 70.8% for dairy. The combinations approach showed 83.0% of individuals had two to five low scoring components, with men, younger adults aged 18&ndash, 30 years and individuals with obesity (BMI &ge, 30) more likely to have five or more. The most common dietary pattern combination included low scores for discretionary choices, dairy and healthy fats. There was a considerable but systematic variation in the low scoring components within the dietary patterns, suggesting that interventions with the flexibility to address particular combinations of key food groups across subgroups could be an effective and resource efficient way to improve diet quality in the population.

The COVID-19 pandemic has dramatically impacted lifestyle behaviour as public health initiatives aim to "flatten the curve". This study examined changes in activity patterns (physical activity, sedentary time, sleep), recreational physical activities, diet, weight and wellbeing from before to during COVID-19 restrictions in Adelaide, Australia. This study used data from a prospective cohort of Australian adults (parents of primary school-aged children; n = 61, 66% female, aged 41±6 years). Participants wore a Fitbit Charge 3 activity monitor and weighed themselves daily using Wi-Fi scales. Activity and weight data were extracted for 14 days before (February 2020) and 14 days during (April 2020) COVID-19 restrictions. Participants reported their recreational physical activity, diet and wellbeing during these periods. Linear mixed effects models were used to examine change over time. Participants slept 27 minutes longer (95% CI 9-51), got up 38 minutes later (95% CI 25-50), and did 50 fewer minutes (95% CI -69-29) of light physical activity during COVID-19 restrictions. Additionally, participants engaged in more cycling but less swimming, team sports and boating or sailing. Participants consumed a lower percentage of energy from protein (-0.8, 95% CI-1.5-0.1) and a greater percentage of energy from alcohol (0.9, 95% CI 0.2-1.7). There were no changes in weight or wellbeing. Overall, the effects of COVID-19 restrictions on lifestyle were small; however, their impact on health and wellbeing may accumulate over time. Further research examining the effects of ongoing social distancing restrictions are needed as the pandemic continues Refereed/Peer-reviewed

Background Almost one in three Australian adults are now obese, and the rate continues to rise. The causes of obesity are multifaceted and include environmental, cultural and lifestyle factors. Emerging evidence suggests there may be temporal patterns in weight gain related, for example, to season and major festivals such as Christmas, potentially due to changes in diet, daily activity patterns or both. The aim of this study is to track the annual rhythm in body weight, 24 h activity patterns, dietary patterns, and wellbeing in a cohort of Australian adults. In addition, through data linkage with a concurrent children’s cohort study, we aim to examine whether changes in children’s body mass index, activity and diet are related to those of their parents. Methods A community-based sample of 375 parents aged 18 to 65 years old, residing in or near Adelaide, Australia, and who have access to a Bluetooth-enabled mobile device or a computer and home internet, will be recruited. Across a full year, daily activities (minutes of moderate to vigorous physical activity, light physical activity, sedentary behaviour and sleep) will be measured using wrist-worn accelerometry (Fitbit Charge 3). Body weight will be measured daily using Fitbit wifi scales. Self-reported dietary intake (Dietary Questionnaire for Epidemiological Studies V3.2), and psychological wellbeing (WHOQOL-BREF and DASS-21) will be assessed eight times throughout the 12-month period. Annual patterns in weight will be examined using Lowess curves. Associations between changes in weight and changes in activity and diet compositions will be examined using repeated measures multi-level models. The associations between parent’s and children’s weight, activity and diet will be investigated using multi-level models. Discussion Temporal factors, such as day type (weekday or weekend day), cultural celebrations and season, may play a key role in weight gain. The aim is to identify critical opportunities for intervention to assist the prevention of weight gain. Family-based interventions may be an important intervention strategy. Trial registration Australia New Zealand Clinical Trials Registry, identifier ACTRN12619001430123. Prospectively registered on 16 October 2019.

BACKGROUND Obesity is a global public health challenge, and there is a need for more evidence-based self-management programs that support longer-term, sustained weight loss. OBJECTIVE This study used data from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Total Wellbeing Diet Online program to determine the reach and weight loss results over its first 5 years. METHODS Participants were adults who joined the commercial weight loss program of their own volition between October 2014 and September 2019 (N=61,164). Information collected included year of birth, sex, height, weight, and usage data (eg, entries into the food diary, views of the menu, and program content). Weight loss and percentage of starting body weight lost were calculated. Members were divided into 2 groups for analysis: “stayers” were members who signed up for at least 12 weeks of the program and recorded a weight entry at baseline and at the end of the program, while “starters” began the program but did not record a weight after 12 weeks. Descriptive statistics and multiple linear regression were used to describe weight loss and determine the member and program characteristics associated with weight loss. RESULTS Data were available from 59,686 members for analysis. Members were predominately female (48,979/59,686, 82.06%) with an average age of 50 years (SD 12.6). The average starting weight was 90.2 kg (SD 19.7), and over half of all members (34,195/59,688, 57.29%) were classified as obese. At week 12, 94.56% (56,438/59,686) of the members had a paid program membership, which decreased to 41.48% (24,756/59,686) at 24 weeks. At week 12, 52.03% (29,115/55,958) of the remaining members were actively using the platform, and by week 24, 26.59% (14,880/55,958) were using the platform. The average weight loss for all members was 2.8 kg or 3.1% of their starting body weight. Stayers lost 4.9 kg (5.3% of starting body weight) compared to starters, who lost 1.6 kg (1.7% of starting body weight). Almost half (11,082/22,658, 48.91%) the members who stayed on the program lost 5% or more of their starting body weight, and 15.48% (3507/22,658) achieved a weight loss of 10% or more. Of the members who were classified as class 1 obese when they joined the program, 41.39% (3065/7405) who stayed on the program were no longer classified as obese at the end, and across all categories of obesity, 24% (3180/13,319) were no longer classified as obese at the end of the program. Based on multiple linear regression, platform usage was the strongest predictor of weight loss (β=.263; P CONCLUSIONS This comprehensive evaluation of a commercial, online weight loss program showed that it was effective for weight loss, particularly for members who finished the program and were active in using the platform and tools provided. If the results demonstrated here can be achieved at an even greater scale, the potential social and economic benefits will be extremely significant.

Background Large-scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features that are appealing for health-related behavior change interventions. Objective This study aimed to describe the implementation and evaluation of a mobile phone app called VegEze, which aims to increase vegetable intake among Australian adults. Methods To capture the impact of this app in a real-world setting, the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was utilized. An uncontrolled, quantitative cohort study was conducted, with evaluations after 21 and 90 days. The app was available in the Apple App Store and was accompanied by television, radio, and social media promotion. Evaluation surveys were embedded into the app using ResearchKit. The primary outcomes were vegetable intake (servings per day) and vegetable variety (types per day). Psychological variables (attitudes, intentions, self-efficacy, and action planning) and app usage were also assessed. Descriptive statistics and multiple linear regression were used to describe the impact of the app on vegetable intake and to determine the characteristics associated with the increased intake. Results Data were available from 5062 participants who completed the baseline survey; 1224 participants completed the 21-day survey, and 273 completed the 90-day survey. The participants resided across Australia and were mostly women (4265/5062, 84.3%) with a mean age of 48.2 years (SD 14.1). The mean increase in intake was 0.48 servings, from 3.06 servings at baseline to 3.54 servings at the end of the 21-day challenge (t1223=8.71; P Conclusions The VegEze app was able to increase intake by half a serving in a large sample of Australian adults. Testing the app in a real-world setting and embedding the consent process allowed for greater reach and an efficient, robust evaluation. Further work to improve engagement is warranted.

Food systems vitally depend on croplands, which are a scarce natural resource. Croplands are also heterogeneous, differing in productive capability and in environmental context. Some are in regions of high biodiversity conservation importance, others in regions vulnerable to food insecurity. In this study, life cycle assessment was used to quantify cropland scarcity footprints, cropland biodiversity footprints and cropland malnutrition footprints for 9341 individual Australian adult daily diets. Dietary cropland scarcity footprints averaged 7.1 m2yr-e person&minus, 1 day&minus, 1, exceeding a target of 6.1 m2yr-e person&minus, 1, consistent with the proposed global cropland planetary boundary of 15% of the ice-free land area. Discretionary foods, which are energy-dense and nutrient-poor foods high in saturated fat, added sugars and salt, and alcohol and are not essential to a healthy diet, made the largest contribution, followed by fresh meats and alternatives, breads and cereals, fruit, dairy and alternatives and vegetables. Around 45% of the variation in cropland footprint between individuals was explained by differences in total dietary energy intake. Diets characterised by higher diet quality and lower cropland scarcity footprint required only 4.2 m2yr-e person&minus, 1 and recommended diets based on the food choices of this subgroup required 5.9 m2yr-e person&minus, 1. Eating within the global cropland planetary boundary appears realistic if Australians greatly reduce their intake of discretionary foods and moderate their food choices within the &ldquo, meat and alternatives&rdquo, food group.

Overconsumption of energy-dense, nutrient-poor "discretionary" foods and beverages can indicate poor diet quality, which is a risk factor for obesity and chronic disease. With 60% of Australians exceeding the recommended intake of discretionary foods, there is a need for interventions to reduce their consumption.The objective was to model the impact of 26 specific scenarios to limit discretionary food intake on energy and nutrient intake.The scenario modeling analysis was based on reduction strategies targeting portion size, frequency, or variety of discretionary food and beverage items consumed.Data from 12,153 respondents aged 2 to 85 years from the 2011-12 Australian National Nutrition and Physical Activity Survey were used.The outcome measures were change in servings of discretionary foods and key nutrients (energy, total fat, saturated fat, sugar, alcohol, sodium, trans fat) for the population, and by sex, age group, weight status, and socioeconomic status.Descriptive and inferential statistical analysis were conducted.Scenarios reduced total energy intake by up to 26% across the population as a whole. The removal of discretionary foods (not beverages) resulted in the greatest reduction in servings and energy (74.8% and 25.6%, respectively), followed by the removal of discretionary items in portions greater than 143 kcal (59.1% and 24.3%) and not consuming discretionary items at main meals (51.2% and 17.8%). Targeting single categories of discretionary foods reduced energy intake by an average of 5.6% for the removal of cakes and biscuits, 4.4% for alcohol, and 3.9% for sugar-sweetened beverages. Strategies reduced total fat, saturated fat, and sugar by up to 35%, 38%, and 40% respectively.Strategies that are specific to discretionary food and beverage intake targeting reductions in portion size, frequency, or variety have the potential to reduce energy intake and improve diet quality. These findings have implications for designing interventions with potential to tailor messages to current dietary habits. Exploration of how these strategies could be effectively implemented will be the focus of further research.

Objective:To (i) describe the adaptation of the Short Food Survey (SFS) for assessing the dietary intake of children (2–5 years) during attendance at Early Childhood Education and Care (SFS-ECEC); (ii) determine the acceptability and feasibility of the SFS-ECEC; and (iii) compare the SFS-ECEC to direct observations for assessing dietary intake of children in care.Design:The adapted forty-seven-item SFS-ECEC was completed by childcare educators to capture individual child’s usual intake over the past month. Acceptability and feasibility were assessed via educator self-report and completion rates. Mean servings of food groups consumed in accordance with dietary guidelines reported in the SFS-ECEC were compared to those obtained by a single-day direct observation via visual estimation conducted by trained personnel. Mean differences, intra-class correlations, Bland–Altman plots, percentage agreement and Cohen’s κ were examined.Setting:Early Childhood Education and Care, NSW, Australia.Participants:Educators and children.Results:213 (98·61 %) SFS-ECECs were returned. Acceptability was high with 86·54 % of educators reporting the tool as easy to understand. Mean differences in servings of food groups between the SFS-ECEC and direct observation were statistically significantly different for five out of six foods and ranged 0·08–1·07, with intra-class correlations ranging 0·00–0·21. Agreement between the methods in the classification of children meeting or not meeting dietary guidelines ranged 42·78–93·01 %, with Cohen’s κ ranging −0·03 to 0·14.Conclusions:The SFS-ECEC is acceptable and feasible for completion by childcare educators. While tool refinement and further validation is warranted, small mean differences suggest the tool may be useful in estimating group-level intakes.

Food choice is strongly driven by the sensory characteristics of foods with sweet, salty and fatty mouthfeel considered highly palatable and rewarding. Attempts to improve diet quality have not addressed sensory characteristics of diets before. This report describes a data modelling exercise that could underpin a dietary strategy to help support consumption of higher quality diets without compromising sensory preferences. This study used the Australian National Nutrition and Physical Activity Survey data (in 9341 adults) and the CSIRO sensory-diet database. A method was developed to find core food swaps which had a similar sensory profile as discretionary foods. This study investigated the impact of such swaps on energy and nutrient intake and the impact of the swaps on servings of food groups. The modelling resulted in a similar sensory profile of core foods to that of discretionary foods with hardness, sweetness and fatty mouthfeel all within 1-3% but the saltiness approached a 4% change. There was a small (3.6%) increase in energy intake. This swap strategy decreased the intake of risk nutrients such as saturated fat and added sugars, but not sodium, while increasing the intake of beneficial nutrients like calcium, zinc and vitamin C. Results also show that there was an increase in the intake of servings of core food groups such as fruits, grains, and dairy products but little change in vegetables. In conclusion, similar sensory swaps are possible and could underpin a diet strategy, that could be further refined through food appropriateness, to improve quality.

The relationship between sensory characteristics of foods, diets and weight status is not well established. However, such knowledge could assist in better understanding food choices and inform strategies to improve diet quality. The objectives of this study were to examine the sensory characteristics of diets varying in healthiness and to explore differences by demographics, weight status and diet quality. Data were captured using the online CSIRO Healthy Diet Score survey, including 38 questions on the frequency and quantity of foods consumed, facilitating the calculation of an overall diet quality score out of 100. Data from 145,975 Australian adults are reported. Sensory characteristics of 105 foods and beverages representative of the survey’s food groups were described using a trained sensory panel in terms of basic tastes, fatty mouthfeel and flavour strength. Average sensory scores (weighted by frequency of consumption) were calculated for each food group question. Reported intake (in serves) was multiplied by the sensory scores for each food group consumed to estimate the total sensory value of the diet. Higher diet quality was associated with higher sweet and bitter scores, but a greater proportion of this sweetness was from healthy core foods rather than discretionary foods. Salty taste tended to be lower in diets of higher quality, and there were no differences in fatty mouthfeel by diet quality. Overall flavour intensity increased with diet quality. For the first time the sensory characteristics of foods pertaining to recommended healthy diets can be described. Consumers, industry and public health could utilise such knowledge to encourage the adoption of higher quality diets.

Background and objective The effectiveness of obesity prevention interventions to improve children's diet can be enhanced. Deconstructing past interventions can identify components with potential to change behaviour. This systematic review using the Behaviour Change Wheel aimed to examine the behaviour change content of interventions supporting parents of 3- to 8-year olds to reduce provision of unhealthy foods to children. Methods Ebscohost, Ovid, Scopus and Web of Science were searched. Eligible studies included controlled interventions with active parent involvement, at least one intervention strategy and outcome measure for unhealthy foods ≥3 months from baseline. Seventeen interventions were included describing 18 intervention arms. Results Interventions frequently targeted parents' reflective motivation (n = 17) and psychological capability (n = 15), through education (n = 15) or enablement (n = 15) intervention functions and service provision (n = 18) policy category. Only 24 of the 93 behaviour change techniques were used with an average of five techniques used per intervention. Conclusions Existing interventions achieving small reductions in unhealthy food intake are homogenous in approach. There is potential to utilize untapped behaviour change techniques, through comprehensive intervention design and behavioural analysis guided by the Behaviour Change Wheel. Interventions targeting opportunity through persuasion, modelling or environmental restructuring, and using different policy categories are urgently needed to provide an evidence base to inform policy and practice.

AIM Children's intake of discretionary choices is excessive. This study aimed to develop a questionnaire measuring parents' attitudes and beliefs towards limiting provision of discretionary choices, using the Health Action Process Approach model. METHODS The questionnaire items were informed by the Health Action Process Approach model, which extends the Theory of Planned Behaviour to include both motivational (intention) and volitional (post-intention) factors that influence behaviour change. The questionnaire was piloted for content and face validity (expert panel, n = 5; parents, n = 4). Construct and predictive validity were examined in a sample of 178 parents of 4-7-year-old children who completed the questionnaire online. Statistical analyses included exploratory factor analyses, Cronbach's alpha and multiple linear regression. RESULTS Pilot testing supported content and face validity. Principal component analyses identified constructs that aligned with the eight constructs of the Health Action Process Approach model. Internal consistencies were high for all subscales, in both the motivational (Cronbach's alpha 0.77-0.88) and volitional phase (Cronbach's alpha 0.85-0.92). CONCLUSIONS Initial results from validation tests support the development of a new questionnaire for measuring parent attitudes and beliefs regarding provision of discretionary choices to their 4-7-year-old children within the home. This new questionnaire can be used to gain greater insight into parents' attitudes and beliefs that influence ability to limit discretionary choices provision to children. Further research to expand understanding of the questionnaires' psychometric properties would be valuable, including confirmatory factor analysis and reproducibility.

Beverages contribute significantly to dietary intake. Research exploring the impact of beverage types on nutrient intake for Australian Aboriginal and Torres Strait Islander people is limited. A secondary analysis of the Australian Aboriginal and Torres Strait Islander Health Survey 2012–2013 (n = 4109) was undertaken. The daily intake, percentage of consumers, and contribution to total nutrient intake was estimated for 12 beverage categories. Beverage intake contributed to 17.4% of total energy, 27.0% of total calcium, 26.3% of total vitamin C, and 46.6% of total sugar intake. The most frequently consumed beverage categories for children (aged 2 to 18 years) were water, fruit juice/drinks, soft drinks, and cordial; and for adults, water, tea, coffee and soft drinks. The primary sources of beverages with added sugar were fruit juice/drinks (for children), tea (for people living remotely), coffee (for adults in metropolitan/regional areas) and soft drinks (for everyone). Actions to modify beverage intake to improve health should maintain the positive nutrient attributes of beverage intake. This analysis of a large-scale national dietary survey provides benchmarking of beverage intake to support program and policy development to modify intake where this is determined as a priority by the community.

Australia is a food trading nation with a complex food system. Change can have important implications for rural communities, employment, trade, public health nutrition and food security. This study compares Australian food intake scenarios to 2050 with linear projections for Australian agricultural production. The study is distinguished by its nutritional perspective, characterising food balance in terms of basic foods rather than food energy or macronutrients, as well as its systems perspective, taking into account the transformations that occur in food processing and cooking, livestock feed requirements, as well as supply chain and kitchen losses. With Australia’s population projected to increase from around 23 million in 2015 to 37.5 million in 2050, substantial increases in domestic food supply will be required. Although the situation and outlook differ for each commodity, in most respects demand is projected to increase at a greater rate than local production. This suggests that the Australian food system is on a trajectory toward reduced net food exports and increased dependence on imports. This will have implications for Australia’s role in the global food system and presents a change in some of the determinants of national food security. The trajectory of the food system also appears to be at odds with the massive public health challenges associated with diet related disease. These and other implications of an enlarging and increasingly international food system are discussed.

The food system is responsible for around 70% of global freshwater use. Pathways toward responsible consumption and production of food are therefore critically needed to ensure the planetary boundary for freshwater use is not transgressed. There is also an uneven spatial distribution of freshwater resources and human water demands, meaning that water-scarcity is acute in some regions but a lesser concern in others. Quantifying the water-scarcity impacts associated with food consumption is therefore a complex challenge due to the diversity of individual eating patterns, the very large number of individual food products available, and the many different regions where food is grown or processed. To our knowledge, this is the first study to calculate water footprints for a large number of self-selected diets. Life cycle assessment was used to model the water-scarcity footprints of 9,341 individual Australian adult diets obtained through 24-hour recall as part of the most recent Australian Health Survey. Three water-scarcity indicators were used, including the AWARE model recently developed by a project group working under the auspices of the United Nations Environment Programme (UNEP) / Society of Environmental Toxicology and Chemistry (SETAC) Life Cycle Initiative (www.lifecycleinitiative.org). In addition, a diet quality score was calculated for each of these diets. Our objective was to identify pathways toward healthier diets with lower water-scarcity impacts. Dietary water-scarcity footprints averaged 362 L-eq person-1 day-1 and were highly variable (sd. 218 L-eq person-1 day-1), reflecting the diversity of eating habits in the general community. The largest water-scarcity impacts were related to the excessive consumption of discretionary foods (alcoholic beverages, processed meat products, dairy desserts, cream, butter, muesli bars, confectionery, chocolate, biscuits, cakes, waffles, fried potato and extruded snacks, etc.). The potential to reduce dietary water-scarcity impacts is large, although the opportunity to intervene through amended dietary guidelines is not straightforward due to the large variations in water-scarcity footprint intensity between individual foods within a food group, and the inability of consumers to identify lower water-scarcity footprint products without food labeling. Reductions in the water-scarcity footprint of Australian food consumption are likely best achieved through reductions in food waste, technological change to improve water-use efficiency in food production, as well as the implementation of product reformulation and procurement strategies in the food manufacturing sector to avoid higher water-scarcity footprint intensity ingredients.

Background Few people successfully maintain lost weight over the longer term. Mobile phones have the potential to deliver weight loss management programs that can encourage self-monitoring while also providing some behavioral therapy to assist users in developing personal skills that may be necessary for improved longer term weight loss maintenance. Objective The aim of this study was to evaluate a program supporting weight maintenance, which uses a behaviorally based mobile phone app to manage weight, food, exercise, mood, and stress. Methods In a randomized controlled trial over 24 weeks, the full version of the app (MotiMate) was compared with a control app (monitoring only; excluding mood and stress) for its effect on weight, diet, and psychological well-being. Both apps had the same visual appearance and were designed to deliver all intervention content without face-to-face contact. The control version included features to track weight, food intake, and exercise with limited feedback and no encouraging/persuasive features. The intervention app included more persuasive and interactive features to help users track their weight, food intake, and physical activity and prompted users to enter data each day through notifications and included a mood and stress workshopping tool. Participants were recruited through advertising and existing databases. Clinic visits occurred at baseline, 4 weeks, 8 weeks, 12 weeks, and 24 weeks. At all visits, the clinical trial manager recorded body weight, and participants then completed a computer-delivered survey, which measured psychological and lifestyle outcomes. Objective app usage data were recorded throughout the trial. Results A total of 88 adults who had lost and maintained at least 5% of their body weight within the last 2 years were randomized (45 MotiMate and 43 control). Overall, 75% (66/88) were female, and 69% (61/88) completed week 24 with no differences in dropout by condition (χ21,87=0.7, P=.49). Mixed models suggested no significant changes in weight or psychological outcomes over 24 weeks regardless of condition. Of 61 completers, 53% (32/61) remained within 2% of their starting weight. Significant increases occurred over 24 weeks for satisfaction with life and weight loss self-efficacy regardless of app condition. Diet and physical activity behaviors did not vary by app or week. Negative binomial models indicated that those receiving the full app remained active users of the app for 46 days longer than controls (P=.02). Users of the full version of the app also reported that they felt more supported than those with the control app (P=.01). Conclusions Although some aspects of the intervention app such as usage and user feedback showed promise, there were few observable effects on behavioral and psychological outcomes. Future evaluation of the app should implement alternative research methods or target more specific populations to better understand the utility of the coping interface. Trial Registration Australia New Zealand Clinical Trials Registry ACTRN12614000474651; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366120

Parents are an ideal target to reduce children&rsquo, s unhealthy food intake. Motivation is one component of behavior change, however, there is a paucity of research exploring parental motivation in unhealthy food provision. This study aimed to understand the relationships between, and relative importance of, constructs of parents&rsquo, reflective motivation and children&rsquo, s intake of unhealthy foods. An online survey captured parent-rated reflective motivation constructs based on the health action process approach (HAPA) model, and children&rsquo, s intake of unhealthy food using the short food survey. The HAPA model includes constructs of self-efficacy, risk perception, outcome expectancies, intention, and planning. Structural equation modelling was used to examine relationships between constructs and the HAPA model in its structural form. Four-hundred and ninety-five parents of three to seven-year olds completed the study. Model fit statistics (X2 = 210.03, df = 83, p &lt, 0.001, Comparative fit index (CFI) = 0.96, Tucker Lewis index (TLI) = 0.94) supported suitability of the HAPA model. The HAPA model explained 9.2% of the variance in children&rsquo, s unhealthy food intake. Constructs of self-efficacy (action to maintenance &beta, = 0.69, maintenance to recovery &beta, = 0.70, maintenance to planning &beta, = 0.82) were found to be the most important constructs for reducing children&rsquo, s unhealthy food intake, followed by planning (to unhealthy food intake &beta, = &minus, 0.32) and intention (to planning &beta, = 0.21). This study provides an initial insight into parental motivation and identifies primary intervention targets to enhance parental motivation to reduce unhealthy food provision, and subsequently children&rsquo, s unhealthy food intake.

Fish and seafood consumption in Australia has been growing, yet the implications of this trend across the food system, from both a health and sustainability perspective have not been fully explored. This paper aims to map out the fish and seafood food system in Australia, linking production and consumption, to articulate challenges and opportunities for enhancing the sector&rsquo, s contribution to future healthy and sustainable diets. We conducted a secondary analysis of publicly available datasets on fish and seafood production and consumption, triangulated and supplemented with peer-reviewed and grey literature on environmental, economic and social sustainability issues throughout the food system. A key challenge for health is the high proportion of fish and seafood consumed as discretionary food, particularly among children. Key challenges for sustainability include the narrow focus on environmental sustainability (with little consideration of the other domains), and the focus on production with little consideration for sustainability throughout post-harvest handling, processing, retail, distribution and consumption. Key opportunities for health and sustainability include the innovative use of processing and packaging technology to maximise nutritional quality, creation of markets and supply chains for a greater diversity of underutilised fish and seafood species and processing by-products, and reductions in waste and loss throughout the entire supply chain.