The burden of cardiovascular disease attributable to high dietary sodium intake in Australia between 1990 and 2019.

BACKGROUND: Diets high in sodium are associated with adverse cardiovascular outcomes. We aimed to quantify the burden of cardiovascular disease (CVD) attributable to high dietary sodium consumption in the Australian population. METHODS: Using data from the Global Burden of Disease (GBD) 2019, we estimated the age-standardised rates (per 100 000 population) and the total numbers of years lived with a disability (YLDs), years of life lost (YLLs), disability-adjusted life years (DALYs), and deaths for CVD attributable to high sodium (≥1000 mg/day) consumption in the Australian population, by sex and age groups (≥25 years) between 1990 and 2019. The study compared Australian estimates with similar high-income countries (Group of 20 [G20] members). RESULTS: From 1990 to 2019, the age-standardized rates of CVD deaths, DALYs, YLDs, and YLLs per 100 000 population in Australia attributable to high sodium decreased. However, between 2013 and 2019, the total number of CVD deaths increased, and the number of CVD YLDs increased exponentially for both sexes for the whole period between 1990 and 2019. Men had a two-fold higher rate for high sodium CVD burden, compared to females between 1990 to 2019. Individuals aged between 80 and 84 years had the highest rates of CVD burden during the same period; however, older age groups reported the greatest decline in CVD burden compared to young and middle-aged adults in Australia. The age-standardised rates for high sodium attributable CVD consistently contributed more towards DALYs than YLDs in 2019 for both sexes. When compared to G20 countries, Australians displayed the lowest age-standardized rates for CVD deaths, DALYs, YLDs, and YLLs alongside Turkey, France, and the United Kingdom in 2019. CONCLUSION: While age-standardized CVD burden attributable to high sodium consumption decreased for both sexes over the past 30 years, the total number of CVD deaths showed an increase between 2013 and 2019. This study underscores the need for sustained efforts to address the rising absolute number of CVD deaths, especially among men and older people, and emphasizes the importance of continued vigilance in monitoring and implementing strategies to reduce the impact of high sodium consumption on cardiovascular health in Australia.

Breastfeeding and the Longitudinal Changes of Body Mass Index in Childhood and Adulthood: A Systematic Review.

Mounting evidence supports the beneficial role of breastfeeding in lowering obesity risk, but the enduring impact of breastfeeding on longitudinal changes in body mass index (BMI) (i.e., BMI trajectories) remains unclear. This systematic review summarized evidence on how breastfeeding influenced the longitudinal trajectories of BMI later in life. Literature searches were conducted in Medline, Embase, Web of Science, and ScienceDirect to identify studies that assessed how breastfeeding (versus other feeding types or duration) was associated with longitudinal trajectories of BMI or BMI z-score. Three randomized controlled trials (RCTs) and 24 longitudinal cohort studies were included. Two-thirds (18/27) of studies were rated as acceptable or high quality. Most cohort studies (9/11) showed that children who continued to breastfeed at 3 to 12 mo of age had a lower BMI trajectory or lower odds of following a high BMI trajectory than those who were formula-fed or mixed-fed. The BMI differences between breastfeeding and other feeding groups were evident from age 7 mo and remained up to 8 y, and the magnitude of between-group BMI differences increased with age. For breastfeeding duration, 12 out of 15 cohort studies found that longer breastfeeding duration was associated with lower BMI trajectories up to age 18 y. Moreover, beneficial associations were observed for both exclusive and any breastfeeding with BMI trajectory. In contrast, mixed findings were reported from 3 RCTs that compared BMI trajectories from birth to ages 12 to 24 mo between breastfeeding promotion versus control or breastfeeding versus formula-feeding groups. The current review provides further longitudinal evidence from cohort studies that breastfeeding versus formula/mixed feeding or longer breastfeeding duration was associated with lower BMI trajectories. Such associations initiated in early childhood became more apparent with age and were sustained into early adulthood. The existing evidence substantiates the importance of breastfeeding promotion and continuation to support obesity prevention.

Outcomes of a state-wide salt reduction initiative in adults living in Victoria, Australia.

PURPOSE: To assess any effects of a state-wide sodium reduction intervention on sodium intake, sources of dietary sodium and discretionary salt use at a population level. METHODS: Data (24-h urinary sodium excretion, self-report survey, a 24-h dietary recall) were collected cross-sectionally at baseline (2016/2017) and follow-up (2020) from adults in Victoria, Australia. Intervention activities included consumer awareness advertising campaign, public debate generation via mass media, strengthening existing policy initiatives and supporting food innovation with industry. RESULTS: There were 339 participants at baseline and 211 at follow-up, with 144 and 90 of participants completing a 24-h dietary recall, respectively. There was no difference in adjusted 24-h urinary sodium excretion between baseline and follow-up (134 vs 131 mmol/24 h; p = 0.260). There were no differences in the percentage of participants adding salt during cooking (63% vs 68%; p = 0.244), adding salt at the table (34% vs 37%; p = 0.400) or regularly taking action to control salt/sodium intake (22% vs 21%; p = 0.793). There were large differences in the quantity of dietary sodium sourced from retail stores (57% vs 77%, p < 0.001), and less sodium was sourced from foods at fresh food markets (13% vs 2%; p ≤ 0.001) at follow-up. No large differences were apparent for foods with different levels of processing or for food groups. CONCLUSION: There was no clear population-level effect of the 4-year multi-component Victorian Salt Reduction Intervention on sodium intake with Victorian adults continuing to consume sodium above recommended levels. The findings indicate that more intensive and sustained efforts aiming at the retail and food industry with national level support are likely to be required to achieve a measurable improvement in sodium intake at a state level.

Dietary Intake and Arterial Stiffness in Children and Adolescents: A Systematic Review.

Arterial stiffness is a risk factor for cardiovascular disease that is affected by diet. However, research understanding how these dietary risk factors are related to arterial stiffness during childhood is limited. The purpose of this review was to determine whether various dietary factors were associated with arterial stiffness in the pediatric population. Five databases were systematically searched. Intervention studies, cross-sectional and cohort studies were included that investigated nutrient or food intake and outcomes of arterial stiffness, primarily measured by pulse wave velocity (PWV) and augmentation index (AIx), in the pediatric population (aged 0-18 years). A final 19 studies (six intervention and 13 observational) were included. Only two intervention studies, including a vitamin D and omega-3 supplementation trial, found protective effects on PWV and AIx in adolescents. Findings from observational studies were overall inconsistent and varied. There was limited evidence to indicate a protective effect of a healthy dietary pattern on arterial stiffness and an adverse effect of total fat intake, sodium intake and fast-food consumption. Overall, results indicated that some dietary factors may be associated with arterial stiffness in pediatric populations; however, inconsistencies were observed across all study designs. Further longitudinal and intervention studies are warranted to confirm the potential associations found in this review.

Changes in sodium levels in Australian packaged foods between 2014 and 2019: an interrupted time series analysis of the impact of the Victorian Salt Reduction Partnership's media advocacy strategy.

BACKGROUND: The Victorian Salt Reduction Partnership (VSRP) implemented a media advocacy strategy (intervention) to stimulate food manufacturers to reduce sodium levels across targeted Australian packaged foods between 2017 and 2019. This study assessed changes in sodium levels of targeted and non-targeted packaged foods during the intervention (2017 to 2019) compared to before the intervention (2014 to 2016) in Australia. METHODS: Annually collected branded-food composition data from 2014 to 2019 were used. Interrupted time series analyses was conducted to compare the trend in sodium levels in packaged foods during the intervention (2017-2019) to the trend in the pre-intervention period (2014-2016). The difference between these trends was derived to estimate the effect of the intervention. RESULTS: A total of 90,807 products were included in the analysis, of which 14,743 were targeted by the intervention. The difference in before and during intervention trends between targeted and non-targeted food categories was 2.59 mg/100 g (95% CI: -13.88 to 19.06). There was a difference in the pre-intervention slope (2014, 2015, 2016) and intervention slope (2017, 2018, 2019) for four of 17 targeted food categories. There was a decrease in sodium levels (mg/100 g) in one food category: frozen ready meals (-13.47; 95% CI: -25.40 to -1.53), and an increase in three categories: flat bread (20.46; 95% CI: 9.11 to 31.81), plain dry biscuits (24.53; 95% CI: 5.87 to 43.19), and bacon (44.54; 95% CI: 6.36 to 82.72). For the other 13 targeted categories, the difference in slopes crossed the line of null effect. CONCLUSIONS: The VSRP's media advocacy strategy did not result in a meaningful reduction in sodium levels of targeted packaged food products during the intervention years compared to trends in sodium levels before the intervention. Our study suggests media advocacy activities highlighting the differences in sodium levels in packaged food products and industry meetings alone are not sufficient to lower average sodium levels in packaged foods in the absence of government leadership and measurable sodium targets.

Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia.

From 2015 to 2020 a state-wide salt-reduction initiative was launched in Victoria, Australia, including an awareness campaign focused on parents with children <18 years of age. To evaluate the impact of the campaign on salt-related knowledge, attitudes and behaviors (KABs) we have assessed trends in salt-related KAB pre- and post-delivery of the campaign in parents, as well as within the wider adult population. Cross-sectional surveys of adults aged 18-65 years were undertaken pre- (2015: n = 821 parents; n = 1527 general sample) and post-campaign (2019: n = 935 parents; n = 1747 general sample). KABs were assessed via an online survey. Data were analyzed with regression models and adjusted for covariates. Among parents, around one-quarter of salt-related KABs shifted in a positive direction, but changes were small: there was a 6% (95% CI 2, 11%) increase in the percentage who knew the main source of salt in the diet and reductions in the percentage who reported placing a salt shaker on the table (-8% (95%CI -12, -3)) and that their child added salt at the table (-5% (95% -9, -0.2)). Among the wider adult sample, even fewer shifts in KAB were observed, with some behaviors worsening at follow-up. These findings indicate that this consumer awareness campaign had minimum impact.

Non-nutritive sweetener regulation and health: analysing applications to vary Australian and New Zealand food standards.

We aimed to understand the process of setting or varying food standards related to non-nutritive sweeteners (NNS) in Australia and New Zealand. Overconsumption of added sugars is a risk factor for non-communicable diseases. Limiting added sugar consumption is recommended by the World Health Organization. NNS are sweet substances with little to no energy that can be used to maintain the sweetness of packaged food when added sugar is reduced. The health and dietary pattern impacts of NNS are contested. Understanding how and why applications for NNS are submitted, assessed and approved within food regulatory systems is important to contextualize the increasing availability of NNS in the food supply. We completed an interpretive content analysis of applications to change the Food Standards Australia and New Zealand (FSANZ) Code, risk assessments and stakeholder submissions. Literature used in risk assessments were drawn from a mixture of documents supplied by industry and peer-reviewed studies. Risk assessments were primarily focussed on toxicological outcomes, while broader public health outcomes were not explicitly considered. Consumption data available to FSANZ were collected several years prior to dietary exposure assessments, and thus may not accurately represent current intakes. The study findings raise questions about whether the scope of what constitutes a 'risk' to public health in the setting of food standards needs to extend beyond immediate toxicological and food safety concerns, to include longer-term dietary balance considerations.

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia.

OBJECTIVE: In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention. DESIGN: Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models. SETTING: Victoria, Australia. PARTICIPANTS: Children aged 4-12 years. RESULTS: Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged. CONCLUSION: These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Impact of growth, gonadal hormones, adiposity and the sodium-to-potassium ratio on longitudinal adolescent measures of blood pressure at puberty.

Blood pressure (BP) rises rapidly at puberty. While this is partly due to normal development, factors like excess adiposity and a high intake of dietary sodium relative to potassium may contribute to a true increase in hypertension risk. This study aimed to assess the relative impact of growth, gonadal hormones, adiposity and the sodium-to-potassium ratio (Na:K) on longitudinal BP measures at puberty. This study analysed data from a three-year longitudinal cohort study of pubertal adolescents. Anthropometry, body composition (bio-electrical impedance), serum testosterone and oestradiol (mass spectrometry) were measured annually. Na:K was measured from three-monthly urine samples. These variables were used to predict annual BP measures using mixed modelling and ordinal regression. Data from 325 adolescents (11.7 ± 1.0 y; 55% male) were analysed, showing typical growth patterns at puberty. Systolic BP increased over time in both sexes (p < 0.01), with boys exhibiting a significantly steeper rise compared to girls. Adiposity variables (BMI z-score, percent body fat, fat mass, waist-to-height ratio) strongly and consistently predicted systolic and diastolic BP in both sexes (all p < 0.05). Systolic BP was also significantly and positively related to height (p < 0.05). No associations with BP were identified in either sex for gonadal hormones or Na:K. Similar results were obtained when BP was classified into hypertension categories. Relative to other developmental and diet-related variables tested, adiposity was found to be the strongest most consistent predictor of BP in pubertal adolescents. Findings highlight the importance of dedicated youth obesity management interventions and policy measures for reducing long-term hypertension and cardiovascular disease risks.Australian New Zealand Clinical Trials Registry ACTRN12617000964314.

Global trends in added sugars and non-nutritive sweetener use in the packaged food supply: drivers and implications for public health.

OBJECTIVE: The health implications of excessive added sugar intakes have led to national policy actions to limit their consumption. Subsequently, non-nutritive sweeteners (NNS) may be used to maintain product sweetness. We aimed to assess trends in quantities of added sugars and NNS sold in packaged food and beverages worldwide, and the association between these trends and the number of national policy actions across regions to reduce added sugar consumption. DESIGN: (i) Longitudinal analysis of Euromonitor sales data (2007-2019) to assess the quantity of added sugars (kg) and NNS (g) sold in packaged foods and beverages globally, across regions, and across country income categories; (ii) policy-mapping of policy actions targeting added sugar consumption globally from the NOURISHING database; and (iii) Spearman's correlations to assess the association between national policy actions across regions and changes in added sugar/NNS sales. SETTING: Worldwide. PARTICIPANTS: Not applicable. RESULTS: Per capita volumes of NNS from beverage sales increased globally (36 %). Added sugars from beverage sales decreased in high-income countries (22 %) but increased in upper-middle-income countries (UMIC) and lower-middle-income countries (LMIC) (13-40 %). Added sugars from packaged food sales increased globally (9 %). Regions with more policy actions had a significant increase in NNS quantities from beverage sales (r = 0·68, P = 0·04). The sweetness of the packaged food supply (the sweetness of each NNS and added sugar, relative to sucrose, multiplied by sales volume) increased over time. CONCLUSIONS: The increasing use of NNS to sweeten beverages globally, and in packaged food in UMIC and LMIC, may have health and dietary implications in the future. Their use as a substitute for added sugar should be considered in public health nutrition policymaking.

Agreement between 24-hour urine and 24-hour food recall in measuring salt intake in primary school children in Australia.

BACKGROUND: Monitoring salt consumption in children is essential for informing and implementing public health interventions to reduce children's salt intake. However, collection of 24-hour urines, considered as the most reliable approach, can be especially challenging to school children. This study aimed to assess the agreement between 24-hour urine (24hrU) and 24-hour food recall (24hrFR) in: (1) estimating salt intake in children; (2) classifying salt intakes above the recommended upper level set for children, and; (3) estimating change in mean salt intake over time. METHODS: This study utilised data from two cross-sectional surveys of school children aged 8 to 12 years living in the state of Victoria, Australia. A single 24hrU and 24hrFR were collected from each participant. Suspected inaccurate urine collections and implausible energy intakes were excluded based on pre-defined criteria. The agreement between the two methods was assessed using Bland-Altman methodology, the intraclass correlation coefficient (ICC), and the kappa statistic. The difference between the measured change in salt intake over time using 24hrU and 24hrFR was derived using mixed effects linear regression analysis. RESULTS: A total of 588 participants provided a 24hrU and 24hrFR. Overall, there was no meaningful difference in mean estimated salt intake between the two methods (- 0.2 g/day, 95% CI - 0.5 to 0.1). The Bland-Altman plot showed wide 95% limits of agreement (- 7.2 to 6.8). The ICC between the two methods was 0.13 (95% CI 0.05 to 0.21). There was poor interrater reliability in terms of classifying salt intake above the recommended upper level for children, with an observed agreement of 63% and kappa statistic of 0.11. The change in mean salt intake over time was 0.2 g/day (- 0.4 to 0.7) based on 24hrU, and 0.5 g/day (- 0.0 to 1.1) based on 24hrFR, with a difference-in-differences of 0.4 g/day (- 0.3 to 1.1). CONCLUSIONS: 24hrFR appears to provide a reasonable estimate of mean salt intake as measured by 24hrU in Australian school children. However, similar to previous observations in adults, and of studies exploring other alternative methods for estimating salt intake, 24hrFR is a poor predictor of individual-level salt intake in children.

What are the benefits and risks of nutrition policy actions to reduce added sugar consumption? An Australian case study.

OBJECTIVE: This study aimed to critically analyse Australia's current and proposed policy actions to reduce added sugar consumption. Over-consumption of added sugar is a significant public health nutrition issue. The competing interests, values and beliefs among stakeholders mean they have disparate views regarding which policy actions are preferable to reduce added sugar consumption. DESIGN: Semi-structured interviews using purposive, snowball sampling and policy mapping. Policy actions were classified by two frameworks: NOURISHING (e.g. behaviour change communication, food environment and food system) and the Orders of Change (e.g. first order: technical adjustments, second order: reforming the system, third order: transforming the system). SETTING: Australia. PARTICIPANTS: Twenty-two stakeholders from the food industry, food regulation, government, public health groups and academia. RESULTS: All proposed and existing policy actions targeted the food environment/behaviour change; most were assessed as first-order changes, and reductionist (nutrient specific) in nature. Influences on policy actions included industry power, stakeholder fragmentation, government ideology/political will and public pressure. Few stakeholders considered potential risks of policy actions, particularly of non-nutritive sweetener substitution or opportunity costs for other policies. CONCLUSIONS: Most of Australia's policy actions to reduce added sugar consumption are reductionist. Preferencing nutrient specific, first-order policy actions could reflect the influence of vested interests, a historically dominant reductionist orientation to nutrition science and policy, and the perceived difficulty of pursuing second- or third-order changes. Pursuing only first-order policy actions could lead to 'regrettable' substitutions and creates an opportunity cost for more comprehensive policy aimed at adjusting the broader food system.

Food sources of iodine in schoolchildren and relationship with 24-h urinary iodine excretion in Victoria, Australia.

Dietary recalls have been used previously to identify food sources of iodine in Australian schoolchildren. Dietary assessment can provide information on the relative contributions of individual food groups which can be related to a robust objective measure of daily intake (24-h urinary iodine excretion (UIE)). In Australia, the government has mandated the use of iodised salt in breadmaking to address iodine deficiency. The aim of this study was to determine the dietary intake and food sources of iodine to assess their contribution to iodine excretion (UIE) in a sample of Australian schoolchildren. In 2011-2013, UIE was assessed using a single 24-h urine sample and dietary intake was assessed using one 24-h dietary recall in a convenience sample of primary schoolchildren from schools in Victoria, Australia. Of the 454 children with a valid recall and urine sample, 55 % were male (average age 10·1 (1·3 (sd) years). Mean UIE and dietary iodine intake were 108 (sd 54) and 172 (sd 74) µg/d, respectively. Dietary assessment indicated that bread and milk were the main food sources of iodine, contributing 27 and 25 %, respectively, to dietary iodine. Milk but not bread intake was positively associated with UIE. Multiple regression (adjusted for school cluster, age and sex) indicated that for every 100 g increase in milk consumption, there was a 3 µg/d increase in UIE (ß = 4·0 (se 0·9), P < 0·001). In conclusion, both bread and milk were important contributors to dietary iodine intake; however, consumption of bread was not associated with daily iodine excretion in this group of Australian schoolchildren.

Are there socio-demographic differences in salt behaviours and fruit and vegetable consumption in Australian adults? A nationally representative cross-sectional survey.

BACKGROUND: Diets low in fruit and vegetables and high in salt are among the top dietary risk factors for non-communicable diseases (NCDs). Using a nationally representative sample of Australians, this study aimed to describe self-reported intake of fruit and vegetables, and knowledge, attitudes and behaviours related to salt intake, and determine if there were socio-demographic differences between population subgroups. METHODS: A 2016 cross-sectional survey of Australian adults aged 18 years and over, which comprised 160 questions, including socio-demographic and health-related questions. Descriptive statistics (mean, 95% confidence interval, %) were calculated. Weighted-adjusted logistic regression models were used to determine if there were socio-demographic differences in salt behaviours and fruit and vegetable consumption. RESULTS: A total of 1217 participants completed the survey (51% female). Less than 8% of participants reported consuming the recommended 2 or more serves of fruit and 5 or more serves of vegetables. Almost 60% of participants frequently added salt during cooking/meal preparation and 42% of respondents frequently placed a salt-shaker on the table at mealtimes. There were no consistent patterns between socio-demographic factors and measures of fruit and vegetable consumption and salt behaviours. Differences in at least one measure were found for sex, age, location, education level and weight category. CONCLUSIONS: There were no consistent patterns between socio-demographic factors and salt behaviours and fruit and vegetable intake. Less than recommended intakes of fruit and vegetables and frequent discretionary salt use are placing Australians at risk of diet-related NCDs. Broad population-based policies and programs to improve fruit and vegetable intake and salt behaviours are needed to improve Australian's diets.

The association between dietary sodium intake, adiposity and sugar-sweetened beverages in children and adults: a systematic review and meta-analysis.

Higher intakes of Na may contribute to weight gain. The primary aim of this systematic review and meta-analysis was to examine the relationship between dietary Na intake and measures of adiposity in children and adults. Given the previous link between Na intake and the consumption of sugar-sweetened beverages (SSB), which are a known risk factor for obesity, a secondary aim examining the relationship between Na intake and SSB consumption was assessed. A systematic literature search identified cross-sectional and longitudinal studies and randomised controlled trials (RCT) which reduced dietary Na (≥3 months). Meta-analysis was performed for outcomes with ≥3 studies. Cross-sectionally higher Na intakes were associated with overweight/obesity in adults (five studies; n 11 067; OR 1·74; 95 % CI 1·43, 2·13) and in children (three studies; n 3625, OR 3·29; 95 % CI 2·25, 4·80), and abdominal obesity (five studies; n 19 744; OR 2·04; 95 % CI 1·72, 2·42) in adults. Overall, associations remained in sensitivity analyses which adjusted for energy. Findings from longitudinal studies were inconsistent. RCT in adults indicated a trend for lower body weight on reduced-Na compared with control diets (fifteen studies; n 5274; -0·29 kg; 95 % CI -0·59, 0·01; P = 0·06); however, it is unclear if energy intakes were also altered on reduced-Na diets. Among children higher Na intakes were associated with higher intake of SSB (four studies, n 10 329, b = 22, 16 and 26 g/d); no studies were retrieved for adults. Overall, there was a lack of high-quality studies retrieved. While cross-sectional evidence indicates Na intake was positively associated with adiposity, these findings have not been clearly confirmed by longitudinal studies or RCT.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review.

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Salt-Related Knowledge, Attitudes and Behaviors (KABs) among Victorian Adults Following 22-Months of a Consumer Awareness Campaign.

The Australian population consumes more salt than recommended and this increases the risk of raised blood pressure and cardiovascular disease. In 2015, a state-wide initiative was launched in the Australian state of Victoria to reduce population salt intake. This study examines whether salt-related knowledge, attitudes and behaviors (KABs) of Victorian adults changed following the first 22 months of a consumer awareness campaign targeting parents. Repeated cross-sectional surveys of adults (18-65 years) recruited from research panels. Analyses were weighted to reflect the Victorian population. In both surveys mean age of participants (1584 in 2015 and 2141 in 2018) was 41 years, and 51% were female. This includes 554 parents/caregivers in 2015 and 799 in 2018. Most indicators of KAB remained unchanged. Among parents/caregivers the percentage who agreed limiting salt in their child's diet was important increased by 8% (p = 0.001), and there was a 10% reduction in the percentage who reported placing a saltshaker on the table and a 9% reduction in those who reported their child added salt at the table (both p < 0.001). Some small adverse effects on other indicators were also observed. During the first 22 months of a salt reduction consumer awareness campaign, there were limited changes in KAB overall, however the target audience reported positive changes regarding their children, which aligned with the campaign messages.

Food and nutrition education opportunities within Australian primary schools.

Schools are regarded as a key setting for obesity prevention, providing an opportunity to reach a large number of children, frequently and over a prolonged period, through formal and informal opportunities to learn about health behaviours. However, the low value placed on health versus academic achievement is a barrier to effective implementation of food and nutrition (F&N) education. This study used a qualitative exploratory approach to explore the views of teachers and key health and education sector stakeholders regarding opportunities for F&N education within the Australian primary school setting. To the best of our knowledge, this is the first study to explore this topic from the perspectives of state-level coordination and development through to local-level implementation and support within the Australian primary school context. Only 2.6% of the Victorian Curriculum related to F&N education, taught through two (of seven) learning outcomes: Health and Physical Education, and Technologies. While stakeholders considered child health a priority, and schools an ideal setting for F&N education, barriers included a lack of strategic policy alignment, limited leadership and coordination, a 'crowded curriculum' and poor availability of shelf-ready resources with explicit curriculum links. A cross-curriculum approach was considered essential for F&N education to become embedded as a core component of the curriculum.

Sources of dietary sodium and implications for a statewide salt reduction initiative in Victoria, Australia.

In Victoria, Australia, a statewide salt reduction partnership was launched in 2015. The aim was to measure Na intake, food sources of Na (level of processing, purchase origin) and discretionary salt use in a cross-section of Victorian adults prior to a salt reduction initiative. In 2016/2017, participants completed a 24-h urine collection (n 338) and a subsample completed a 24-h dietary recall (n 142). Participants were aged 41·2 (sd 13·9) years, and 56 % were females. Mean 24-h urinary excretion was 138 (95 % CI 127, 149) mmol/d for Na. Salt equivalent was 8·1 (95 % CI 7·4, 8·7) g/d, equating to about 8·9 (95 % CI 8·1, 9·6) g/d after 10 % adjustment for non-urinary losses. Mean 24-h intake estimated by diet recall was 118 (95 % CI 103, 133) mmol/d for Na (salt 6·9 (95 % CI 6·0, 7·8 g/d)). Leading dietary sources of Na were cereal-based mixed dishes (12 %), English muffins, flat/savoury/sweet breads (9 %), regular breads/rolls (9 %), gravies and savoury sauces (7 %) and processed meats (7 %). Over one-third (38 %) of Na consumed was derived from discretionary foods. Half of all Na consumed came from ultra-processed foods. Dietary Na derived from foods was obtained from retail stores (51 %), restaurants and fast-food/takeaway outlets (28 %) and fresh food markets (9 %). One-third (32 %) of participants reported adding salt at the table and 61 % added salt whilst cooking. This study revealed that salt intake was above recommended levels with diverse sources of intake. Results from this study suggest a multi-faceted salt reduction strategy focusing on the retail sector, and food reformulation would most likely benefit Victorians and has been used to inform the ongoing statewide salt reduction initiative.