Development of a survey tool to assess the environmental determinants of health-enabling food retail practice in Aboriginal and Torres Strait Islander communities of remote Australia.

BACKGROUND: Environmental factors can impact the ability of food retail businesses to implement best practice health-enabling food retail. METHODS: We co-designed a short-item survey on factors influencing food retail health-enabling practice in a remote Australian setting. Publicly available submissions to an Australian Parliamentary Inquiry into food pricing and food security in remote Indigenous communities were coded using an existing remote community food systems assessment tool and thematically analysed. Themes informed survey questions that were then prioritised, refined and pre-tested with expert stakeholder input. RESULTS: One-hundred and eleven submissions were coded, and 100 themes identified. Supply chain related data produced the most themes (n = 25). The resulting 26-item survey comprised questions to assess the perceived impact of environmental factors on a store's health-enabling practice (n = 20) and frequency of occurrence (n = 6). CONCLUSIONS: The application of this evidence-informed, co-designed survey will provide a first-time cross-sectional analysis and the potential for ongoing longitudinal data and advocacy on how environmental factors affect the operations of remote stores.

Benchmarking for healthy food stores: protocol for a randomised controlled trial with remote Aboriginal and Torres Strait Islander communities in Australia to enhance adoption of health-enabling store policy and practice.

BACKGROUND: Aboriginal and Torres Strait Islander communities in remote Australia have initiated bold policies for health-enabling stores. Benchmarking, a data-driven and facilitated 'audit and feedback' with action planning process, provides a potential strategy to strengthen and scale health-enabling best-practice adoption by remote community store directors/owners. We aim to co-design a benchmarking model with five partner organisations and test its effectiveness with Aboriginal and Torres Strait Islander community stores in remote Australia. METHODS: Study design is a pragmatic randomised controlled trial with consenting eligible stores (located in very remote Northern Territory (NT) of Australia, primary grocery store for an Aboriginal community, and serviced by a Nutrition Practitioner with a study partner organisation). The Benchmarking model is informed by research evidence, purpose-built best-practice audit and feedback tools, and co-designed with partner organisation and community representatives. The intervention comprises two full benchmarking cycles (one per year, 2022/23 and 2023/24) of assessment, feedback, action planning and action implementation. Assessment of stores includes i adoption status of 21 evidence-and industry-informed health-enabling policies for remote stores, ii implementation of health-enabling best-practice using a purpose-built Store Scout App, iii price of a standardised healthy diet using the Aboriginal and Torres Strait Islander Healthy Diets ASAP protocol; and, iv healthiness of food purchasing using sales data indicators. Partner organisations feedback reports and co-design action plans with stores. Control stores receive assessments and continue with usual retail practice. All stores provide weekly electronic sales data to assess the primary outcome, change in free sugars (g) to energy (MJ) from all food and drinks purchased, baseline (July-December 2021) vs July-December 2023. DISCUSSION: We hypothesise that the benchmarking intervention can improve the adoption of health-enabling store policy and practice and reduce sales of unhealthy foods and drinks in remote community stores of Australia. This innovative research with remote Aboriginal and Torres Strait Islander communities can inform effective implementation strategies for healthy food retail more broadly. TRIAL REGISTRATION: ACTRN12622000596707, Protocol version 1.

Implementation of a food retail intervention to reduce purchase of unhealthy food and beverages in remote Australia: mixed-method evaluation using the consolidated framework for implementation research.

BACKGROUND: Adoption of health-enabling food retail interventions in food retail will require effective implementation strategies. To inform this, we applied an implementation framework to a novel real-world food retail intervention, the Healthy Stores 2020 strategy, to identify factors salient to intervention implementation from the perspective of the food retailer. METHODS: A convergent mixed-method design was used and data were interpreted using the Consolidated Framework for Implementation Research (CFIR). The study was conducted alongside a randomised controlled trial in partnership with the Arnhem Land Progress Aboriginal Corporation (ALPA). Adherence data were collected for the 20 consenting Healthy Stores 2020 study stores (ten intervention /ten control) in 19 communities in remote Northern Australia using photographic material and an adherence checklist. Retailer implementation experience data were collected through interviews with the primary Store Manager for each of the ten intervention stores at baseline, mid- and end-strategy. Deductive thematic analysis of interview data was conducted and informed by the CFIR. Intervention adherence scores derived for each store assisted interview data interpretation. RESULTS: Healthy Stores 2020 strategy was, for the most part, adhered to. Analysis of the 30 interviews revealed that implementation climate of the ALPA organisation, its readiness for implementation including a strong sense of social purpose, and the networks and communication between the Store Managers and other parts of ALPA, were CFIR inner and outer domains most frequently referred to as positive to strategy implementation. Store Managers were a 'make-or-break' touchstone of implementation success. The co-designed intervention and strategy characteristics and its perceived cost-benefit, combined with the inner and outer setting factors, galvanised the individual characteristics of Store Managers (e.g., optimism, adaptability and retail competency) to champion implementation. Where there was less perceived cost-benefit, Store Managers seemed less enthusiastic for the strategy. CONCLUSIONS: Factors critical to implementation (a strong sense of social purpose; structures and processes within and external to the food retail organisation and their alignment with intervention characteristics (low complexity, cost advantage); and Store Manager characteristics) can inform the design of implementation strategies for the adoption of this health-enabling food retail initiative in the remote setting. This research can help inform a shift in research focus to identify, develop and test implementation strategies for the wide adoption of health-enabling food retail initiatives into practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN 12,618,001,588,280.

Validation of the Thumbs food classification system as a tool to accurately identify the healthiness of foods.

The Thumbs food classification system was developed to assist remote Australian communities to identify food healthiness. This study aimed to assess: (1) the Thumbs system's alignment to two other food classification systems, the Health Star Rating (HSR) and the Northern Territory School Canteens Guidelines (NTSCG); (2) its accuracy in classifying 'unhealthy' (contributing to discretionary energy and added sugars) and 'healthy' products against HSR and NTSCG; (3) areas for optimisation. Food and beverage products sold between 05/2018 and 05/2019 in fifty-one remote stores were classified in each system. System alignment was assessed by cross-tabulating percentages of products, discretionary energy and added sugars sold assigned to the same healthiness levels across the systems. The system/s capturing the highest percentage of discretionary energy and added sugars sold in 'unhealthy' products and the lowest levels in 'healthy' products were considered the best performing. Cohen's κ was used to assess agreement between the Thumbs system and the NTSCG for classifying products as healthy. The Thumbs system classified product healthiness in line with the HSR and NTSCG, with Cohen's κ showing moderate agreement between the Thumbs system and the NTSCG (κ = 0·60). The Thumbs system captured the most discretionary energy sold (92·2 %) and added sugar sold (90·6 %) in unhealthy products and the least discretionary energy sold (0 %) in healthy products. Modifications to optimise the Thumbs system include aligning several food categories to the NTSCG criteria and addressing core/discretionary classification discrepancies of fruit juice/drinks. The Thumbs system offers a classification algorithm that could strengthen the HSR system.

The oxygen saturation of red blood cell concentrates: The basis for a novel index of red cell oxidative stress.

BACKGROUND: Oxidative stress is a major driving force in the development of storage lesions in red cell concentrates (RCCs). Unlike manufactured pharmaceuticals, differences in component preparation methods and genetic/physiological status of donors result in nonuniform biochemical characteristics of RCCs. Various characteristics of donated blood on oxygen saturation (SO2 ) distribution were investigated, and a model to estimate potential oxidative stress burden of stored RCC at transfusion is proposed. STUDY DESIGN AND METHODS: The oxygen content of freshly prepared RCCs (770) was quantified noninvasively as fractional hemoglobin saturation (SO2 ) with visible reflectance spectrometry. Using separate RCCs and mimicking typical handling of RCCs during routine storage, evolution of SO2 was followed for construction of an empirical model. Based on this model, the oxygen exposure index (OEI) was formulated to estimate the accumulated oxygen exposure burden of RCC at the time of transfusion. RESULTS: The SO2 of RCCs varied widely at donation (mean 43% ± 1.3%; range 20%-93%). Multivariate regression model showed that sex and processing method had small effects on SO2 (R2  = 0.12), indicating that variability was mainly attributed to other individual donor characteristics. Storage simulation model indicated that median SO2 increased gradually over 6 weeks (approx. 1.3 fold), while OEI increased at a faster rate (approx. eight-fold). CONCLUSION: In addition to storage age, the OEI provides a potential new metric to assess the quality of RCCs at the time of transfusion in terms of their oxidative stress. In future studies, a single noninvasive measurement during storage could link OEI to clinical outcomes in transfusion recipients.

Impact of three annual tobacco tax rises on tobacco sales in remote Australian Aboriginal community stores.

BACKGROUND: There is strong evidence from many settings that tobacco tax rises which increase prices reduce tobacco consumption, but only limited evidence from Indigenous settings. METHODS: We analysed 3 years (2016-2018) of weekly sales data from 32 stores in remote Aboriginal communities. We used interrupted time series analysis to estimate the immediate impact of the price rice following annual 12.5% tobacco tax rises on sales on (A) stick equivalents of tobacco and (B) fruit and vegetables (kg) per $A1000 of grocery sales, and on the trend in sales between price rises. RESULTS: We detected 5.8% and 8.2% immediate declines in tobacco sales following the price rises associated with annual 12.5% tax rises in 2016 and 2018, and a non-significant decline (1.6%) following the 2017 tax rise. Decreased sales were mainly driven by declines in mainstream and premium factory-made cigarettes. Fruit and vegetable sales did not change at the time of tobacco price rises. CONCLUSION: For the first time, we demonstrated evidence of price-sensitivity and the immediate impact of price rises from tobacco tax rises on tobacco sales in remote Aboriginal communities. We acknowledge that Australia already has very high tobacco taxation and prices, but recommend further increases to the taxation of roll-your-own (RYO) tobacco to prevent smokers and industry using cheaper RYO cigarettes to undermine this impact of high tobacco taxes and prices.

Altered dietary salt intake for people with chronic kidney disease.

BACKGROUND: Evidence indicates that reducing dietary salt may reduce the incidence of heart disease and delay decline in kidney function in people with chronic kidney disease (CKD). This is an update of a review first published in 2015. OBJECTIVES: To evaluate the benefits and harms of altering dietary salt for adults with CKD. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 6 October 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials comparing two or more levels of salt intake in adults with any stage of CKD. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for eligibility, conducted risk of bias evaluation and evaluated confidence in the evidence using GRADE. Results were summarised using random effects models as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS: We included 21 studies (1197 randomised participants), 12 in the earlier stages of CKD (779 randomised participants), seven in dialysis (363 randomised participants) and two in post-transplant (55 randomised participants). Selection bias was low in seven studies, high in one and unclear in 13. Performance and detection biases were low in four studies, high in two, and unclear in 15. Attrition and reporting biases were low in 10 studies, high in three and unclear in eight. Because duration of the included studies was too short (1 to 36 weeks) to test the effect of salt restriction on endpoints such as death, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were examined. Reducing salt by mean -73.51 mmol/day (95% CI -92.76 to -54.27), equivalent to 4.2 g or 1690 mg sodium/day, reduced systolic/diastolic blood pressure by -6.91/-3.91 mm Hg (95% CI -8.82 to -4.99/-4.80 to -3.02; 19 studies, 1405 participants; high certainty evidence). Albuminuria was reduced by 36% (95% CI 26 to 44) in six studies, five of which were carried out in people in the earlier stages of CKD (MD -0.44, 95% CI -0.58 to -0.30; 501 participants; high certainty evidence). The evidence is very uncertain about the effect of lower salt intake on weight, as the weight change observed (-1.32 kg, 95% CI -1.94 to -0.70; 12 studies, 759 participants) may have been due to fluid volume, lean tissue, or body fat. Lower salt intake may reduce extracellular fluid volume in the earlier stages of CKD (-0.87 L, 95% CI -1.17 to -0.58; 3 studies; 187 participants; low certainty evidence). The evidence is very uncertain about the effect of lower salt intake on reduction in antihypertensive dose (RR 2.45, 95% CI 0.98 to 6.08; 8 studies; 754 participants). Lower salt intake may lead to  symptomatic hypotension (RR 6.70, 95% CI 2.40 to 18.69; 6 studies; 678 participants; moderate certainty evidence). Data were sparse for other types of adverse events. AUTHORS' CONCLUSIONS: We found high certainty evidence that salt reduction reduced blood pressure in people with CKD, and albuminuria in people with earlier stage CKD in the short-term. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in CKD progression and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted.

Development and pilot of a tool to measure the healthiness of the in-store food environment.

OBJECTIVE: To rigorously develop a tool which enables rapid yet comprehensive appraisal of the consumer food retail environment and provision of real-time feedback to store managers and owners, based on the '4Ps' principles of marketing. DESIGN: Multi-stage iterative approach including (1) Systematic literature review; (2) Stakeholder consultation; (3) Assessment of existing tools against identified needs; (4) Tool development; (5) Pilot testing and (6) Transition of tool to mobile application (the Store Scout app). SETTING: Northern Territory, Australia. PARTICIPANTS: Nine remote Aboriginal community food stores; public health nutritionists, retailers, store board directors, Aboriginal community members, government representatives. RESULTS: Forty-seven existing tools and thirty-four stakeholder interviews informed the development of the current instrument, which comprised: (1) seven product categories (Fruit & Vegetables, Drinks, Snack Foods, Meals & Convenience Foods, Meat & Seafood, Dairy & Eggs, Breads & Cereals) across the '4Ps' (Product, Placement, Price, Promotion); (2) Store manager questions about context and perceived importance of key principles about the store environment and (3) a scoring and feedback component. The tool was considered feasible and acceptable by all testers. CONCLUSIONS: The developed tool addresses an unmet need to measure the consumer food retail environment across all 4Ps whilst also incorporating manager perspectives and immediate feedback. Our objectives of developing a comprehensive, feasible and acceptable instrument were achieved during pilot testing. The tool will support implementation of best practice within stores to encourage healthy food choices and has potential for broad application in retail settings locally and internationally, as well as for research purposes.

From Surviving to Thriving - Parental Experiences of Hospitalised Infants with Congenital Heart Disease Undergoing Cardiac Surgery: A Qualitative Synthesis.

PROBLEM: Congenital heart disease (CHD) is the most common congenital abnormality in infants and over one third of these infants will require surgical intervention in the neonatal period. This qualitative synthesis aimed to explore parental experiences of surgery and hospitalisation in the intensive care environment for the treatment of their infant's CHD in the first year of life in order to inform practice. ELIGIBILITY CRITERIA: Qualitative primary research and qualitative elements of mixed methods studies published in English between January 2009 and February 2019 were eligible if they addressed the experiences and perspectives of parents whose infants had CHD undergoing cardiac surgery in the first year of life. SAMPLE: Three hundred and forty-nine papers were screened. Six papers, with three of them from the same larger study, were included. RESULTS: Five themes were developed from thematic synthesis. They are (1) intense conflicting emotions from heartbreak to joy, (2) the helplessness and uncertainty of waiting, (3) making sense of it all, (4) the power of relationships, and (5) parenting despite the challenges. CONCLUSION: Parents experienced intense and fluctuating emotions, and found ways of coping. The integral role of healthcare professionals/nurses during this period was also evident. IMPLICATIONS: Healthcare professionals/nurses have the potential to positively impact the care and outcomes for this growing population of infants with CHD and their families, helping them to thrive. More research is needed with longitudinal and multi-centred studies and in middle and low income counties to broaden our understanding of this topic.

Consumer acceptance of reformulated food products: A systematic review and meta-analysis of salt-reduced foods.

Food product reformulation is promoted as an effective strategy to reduce population salt intake and address the associated burden of chronic disease. Salt has a number of functions in food processing, including impacting upon physical and sensory properties. Manufacturers must ensure that reformulation of foods to reduce salt does not compromise consumer acceptability. The aim of this systematic review is to determine to what extent foods can be reduced in salt without detrimental effect on consumer acceptability. Fifty studies reported on salt reduction, replacement or compensation in processed meats, breads, cheeses, soups, and miscellaneous products. For each product category, levels of salt reduction were collapsed into four groups: <40%, 40-59%, 60-79% and ≥80%. Random effects meta-analyses conducted on salt-reduced products showed that salt could be reduced by approximately 40% in breads [mean change in acceptability for reduction <40% (-0.27, 95% confidence interval (CI) -0.62, 0.08; p = 0.13)] and approximately 70% in processed meats [mean change in acceptability for reductions 60-69% (-0.18, 95% CI -0.44, 0.07; p = 0.15)] without significantly impacting consumer acceptability. Results varied for other products. These results will support manufacturers to make greater reductions in salt when reformulating food products, which in turn will contribute to a healthier food supply.

Review of behaviour change interventions to reduce population salt intake.

BACKGROUND: Excess salt intake is a major cause of raised blood pressure-the leading risk factor for death and disability worldwide. Although behaviour change interventions such as awareness campaigns and health education programs are implemented to reduce salt intake, their effectiveness is unclear. This global systematic review investigates the impact of population-level behaviour change interventions that aim to reduce salt intake. METHODS: A search for published and grey literature was conducted using PubMed, Cochrane Library, Embase, Web of Science, Sage, Scopus, OpenGrey, Google Scholar and other relevant organizations' websites. Studies were included if 1) published between 2005 and 2015; 2) the education or awareness-raising interventions were aimed at the population or sub-population and 3) salt intake and/or salt-related behaviours were outcome measures. Study and intervention characteristics were extracted for the descriptive synthesis and study quality was assessed. RESULTS: Twenty two studies involving 41,448 participants were included. Most were conducted in high income countries (n = 16), targeting adults (n = 21) in the general population (n = 16). Behaviour change interventions were categorised as health education interventions (n = 14), public awareness campaigns (n = 4) and multi-component interventions (including both health education and awareness campaigns, n = 4). 19 of the 22 studies demonstrated significant reductions in estimated salt intake and/or improvement in salt-related behaviours. All studies showed high risk of bias in one or more domains. Of the 10 higher quality studies, 5 found a significant effect on salt intake or salt behaviours based on the more objective outcome assessment method. CONCLUSION: Based on moderate quality of evidence, population-level behaviour change interventions can improve salt-related behaviours and/or reduce salt intake. However, closer analysis of higher quality studies show inconsistent evidence of the effectiveness and limited effect sizes suggest the implementation of education and awareness-raising interventions alone are unlikely to be adequate in reducing population salt intake to the recommended levels. A framework which guides rigorous research and evaluation of population-level interventions in real-world settings would help understand and support more effective implementation of interventions to reduce salt intake.

Altered dietary salt intake for people with chronic kidney disease.

BACKGROUND: Salt intake shows great promise as a modifiable risk factor for reducing heart disease incidence and delaying kidney function decline in people with chronic kidney disease (CKD). However, a clear consensus of the benefits of reducing salt in people with CKD is lacking. OBJECTIVES: This review evaluated the benefits and harms of altering dietary salt intake in people with CKD. SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register to 13 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared two or more levels of salt intake in people with any stage of CKD. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for eligibility and conducted risk of bias evaluation. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Mean effect sizes were calculated using the random-effects models. MAIN RESULTS: We included eight studies (24 reports, 258 participants). Because duration of the included studies was too short (1 to 26 weeks) to test the effect of salt restriction on endpoints such as mortality, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were applied. Three studies were parallel RCTs and five were cross-over studies. Selection bias was low in five studies and unclear in three. Performance and detection biases were low in two studies and unclear in six. Attrition and reporting biases were low in four studies and unclear in four. One study had the potential for high carryover effect; three had high risk of bias from baseline characteristics (change of medication or diet) and two studies were industry funded.There was a significant reduction in 24 hour sodium excretion associated with low salt interventions (range 52 to 141 mmol) (8 studies, 258 participants: MD -105.86 mmol/d, 95% CI -119.20 to -92.51; I(2) = 51%). Reducing salt intake significantly reduced systolic blood pressure (8 studies, 258 participants: MD -8.75 mm Hg, 95% CI -11.33 to -6.16; I(2) = 0%) and diastolic blood pressure (8 studies, 258 participants: MD -3.70 mm Hg, 95% CI -5.09 to -2.30; I(2) = 0%). One study reported restricting salt intake reduced the risk of oedema by 56%. Salt restriction significantly increased plasma renin activity (2 studies, 71 participants: MD 1.08 ng/mL/h, 95% CI 0.51 to 1.65; I(2) = 0%) and serum aldosterone (2 studies, 71 participants: 6.20 ng/dL (95% CI 3.82 to 8.58; I(2) = 0%). Antihypertensive medication dosage was significantly reduced with a low salt diet (2 studies, 52 participants): RR 5.48, 95% CI 1.27 to 23.66; I(2) = 0%). There was no significant difference in eGFR (2 studies, 68 participants: MD -1.14 mL/min/1.73 m(2), 95% CI -4.38 to 2.11; I(2) = 0%), creatinine clearance (3 studies, 85 participants): MD -4.60 mL/min, 95% CI -11.78 to 2.57; I(2) = 0%), serum creatinine (5 studies, 151 participants: MD 5.14 µmol/L, 95% CI -8.98 to 19.26; I(2) = 59%) or body weight (5 studies, 139 participants: MD -1.46 kg; 95% CI -4.55 to 1.64; I(2) = 0%). There was no significant change in total cholesterol in relation to salt restriction (3 studies, 105 participants: MD -0.23 mmol/L, 95% CI -0.57 to 0.10; I(2) = 0%) or symptomatic hypotension (2 studies, 72 participants: RR 6.60, 95% CI 0.77 to 56.55; I(2) = 0%). Salt restriction significantly reduced urinary protein excretion in all studies that reported proteinuria as an outcome, however data could not be meta-analysed. AUTHORS' CONCLUSIONS: We found a critical evidence gap in long-term effects of salt restriction in people with CKD that meant we were unable to determine the direct effects of sodium restriction on primary endpoints such as mortality and progression to end-stage kidney disease (ESKD). We found that salt reduction in people with CKD reduced blood pressure considerably and consistently reduced proteinuria. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in ESKD incidence and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted, as is investigation into adherence to a low salt diet.

Dietary sodium and iodine in remote Indigenous Australian communities: will salt-reduction strategies increase risk of iodine deficiency? A cross-sectional analysis and simulation study.

BACKGROUND: Excess salt intake is a global issue. Effective salt-reduction strategies are needed, however, as salt is a vehicle for iodine fortification, these strategies may also reduce iodine intake. This study examines the case of the remote Indigenous Australian population; we employed an innovative, objective method to assess sodium and iodine intakes against requirements and modelled the potential effects of salt-reduction strategies on estimated sodium and iodine intakes. DESIGN: Store-sales data were collected from 20 remote Indigenous community stores in 2012-14 representing the main source of food for 2 years for ~8300 individuals. Estimated average sodium and iodine intakes were compared against recommendations (nutrient reference values weighted to age and gender distribution). Linear programming was employed to simulate potential effects of salt-reduction strategies on estimated sodium and iodine intakes. RESULTS: Estimated average sodium intake was 2770 (range within communities 2410-3450) mg/day, far exceeding the population-weighted upper limit (2060 mg/day). Discretionary (added) salt, bread and processed meat were the biggest contributors providing 46% of all sodium. Estimated average iodine intake was within recommendations at 206 (186-246) µg/day. The following scenarios enabled modelling of estimated average salt intake to within recommendations: 1) 67% reduction in sodium content of bread and discretionary salt intake, 2) 38% reduction in sodium content of all processed foods, 3) 30% reduction in sodium content of all processed foods and discretionary salt intake. In all scenarios, simulated average iodine intakes remained within recommendations. CONCLUSIONS: Salt intakes of the remote Indigenous Australian population are far above recommendations, likely contributing to the high prevalence of hypertension and cardiovascular mortality experienced by this population. Salt-reduction strategies could considerably reduce salt intake in this population without increasing risk of iodine deficiency at the population-level. These data add to the global evidence informing salt-reduction strategies and the evidence that these strategies can be synergistically implemented with iodine deficiency elimination programmes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613000694718.

A randomized trial of sodium-restriction on kidney function, fluid volume and adipokines in CKD patients.

BACKGROUND: Dietary sodium restriction is a key management strategy in chronic kidney disease (CKD). Recent evidence has demonstrated short-term reduction in blood pressure (BP) and proteinuria with sodium restriction, however the effect on other cardiovascular-related risk factors requires investigation in CKD. METHODS: The LowSALT CKD study involved 20 hypertensive Stage III-IV CKD patients counselled by a dietitian to consume a low-sodium diet (<100 mmol/day). The study was a randomised crossover trial comparing 2 weeks of high-sodium (additional 120 mmol sodium tablets) and low-sodium intake (placebo). Measurements were taken after each crossover arm including BP (peripheral and central), adipokines (inflammation markers and adiponectin), volume markers (extracellular-to-intracellular [E/I] fluid ratio; N-terminal pro-brain natriuretic peptide [NT-proBNP]), kidney function (estimated Glomerular Filtration Rate [eGFR]) and proteinuria (urine protein-creatinine ratio [PCR] and albumin-creatinine ratio [ACR]). Outcomes were compared using paired t-test for each cross-over arm. RESULTS: BP-lowering benefits of a low-sodium intake (peripheral BP (mean ± SD) 148/82 ± 21/12 mmHg) from high-sodium (159/87 ± 15/10 mmHg) intake were reflected in central BP and a reduction in eGFR, PCR, ACR, NTproBNP and E/I ratio. There was no change in inflammatory markers, total or high molecular weight adiponectin. CONCLUSIONS: Short-term benefits of sodium restriction on BP were reflected in significant change in kidney function and fluid volume parameters. Larger, long-term adequately powered trials in CKD are necessary to confirm these results. TRIAL REGISTRATION: Universal Trial Number U1111-1125-2149 registered on 13/10/2011; Australian New Zealand Clinical Trials Registry Number ACTRN12611001097932 registered on 21/10/2011.

Taste perception in kidney disease and relationship to dietary sodium intake.

Taste abnormalities are prevalent in Chronic Kidney Disease (CKD) potentially affecting food palatability and intake, and nutrition status. The TASTE CKD study aimed to assess taste and explore the relationship of dietary sodium intake with taste disturbance in CKD subjects. This was a cross-sectional study of 91 adult stage 3-5 CKD participants (78% male) aged 65.9 ± 13.5 years with mean estimated glomerular filtration rate of 33.1 ± 12.7 ml/min/1.73 m(2), and 30 controls (47% male) aged 55.2 ± 7.4 years without kidney dysfunction. Taste assessment was performed in both groups, presenting five basic tastes (sweet, sour, salty, umami and bitter) in blinded 2 ml solution which the participants tasted, identified (identification) and rated perceived strength (intensity) on a 10 cm visual analogue scale. Sodium intake was measured in the CKD group using validated food frequency questionnaire to determine high or low sodium intake (cut-off 100 mmol sodium/day). Differences between groups (CKD vs controls; high vs low sodium intake) were analysed using chi-square for identification and t-test for intensity. Multivariate analysis was used to adjust for age and gender differences between CKD and controls. The control group identified mean 3.9 ± 1.0 tastants correctly compared with 3.0 ± 1.2 for CKD group (p < 0.001), which remained significant after adjustment for age and gender. After adjustment for age and gender, sour identification and intensity and salty and umami intensity were impaired in CKD compared with controls. Participants with low sodium intake were more likely to correctly identify salty and umami, and rated intensity of umami and bitter significantly higher than those with high sodium intake. These findings add to the body of evidence suggesting that taste changes occur with CKD, independent of age and gender differences, with specific impairment in sour, umami and salty tastes. Our finding that sodium intake is related to umami and bitter disturbance as well as salty taste warrants further investigation.

A randomized trial of dietary sodium restriction in CKD.

There is a paucity of quality evidence regarding the effects of sodium restriction in patients with CKD, particularly in patients with pre-end stage CKD, where controlling modifiable risk factors may be especially important for delaying CKD progression and cardiovascular events. We conducted a double-blind placebo-controlled randomized crossover trial assessing the effects of high versus low sodium intake on ambulatory BP, 24-hour protein and albumin excretion, fluid status (body composition monitor), renin and aldosterone levels, and arterial stiffness (pulse wave velocity and augmentation index) in 20 adult patients with hypertensive stage 3-4 CKD as phase 1 of the LowSALT CKD study. Overall, salt restriction resulted in statistically significant and clinically important reductions in BP (mean reduction of systolic/diastolic BP, 10/4 mm Hg; 95% confidence interval, 5 to 15 /1 to 6 mm Hg), extracellular fluid volume, albuminuria, and proteinuria in patients with moderate-to-severe CKD. The magnitude of change was more pronounced than the magnitude reported in patients without CKD, suggesting that patients with CKD are particularly salt sensitive. Although studies with longer intervention times and larger sample sizes are needed to confirm these benefits, this study indicates that sodium restriction should be emphasized in the management of patients with CKD as a means to reduce cardiovascular risk and risk for CKD progression.

Development of a Tool for Reporting Key Dietary Indicators from Sales Data in Remote Australian Aboriginal and Torres Strait Islander Community Stores.

Reporting key dietary indicators from sales data can help us guide store decision makers in developing effective store policy to support healthier customer purchases. We aimed to develop a web-based reporting tool of key dietary indicators from sales data to support health-promoting policy and practice in stores in geographically remote Aboriginal and Torres Strait Islander communities. Tool development included identifying key dietary indicators (informed by sales data from 31 stores), community consultation (19 Aboriginal and Torres Strait Islander store directors and two store managers) and a web-build. Tool evaluation involved feedback interviews with stakeholders (25 store managers and two nutritionists). Key dietary indicators aligned with Australian Dietary Guideline food groupings and recommendations. An online portal for accessing and customising reports was built. Stakeholder feedback indicated that the strengths of the reports were the visuals, ease of interpretation, providing information that was not currently available and potential to increase capacity to support healthy food retailing. Difficulties were defining healthiness classification with alignment to other nutrition guidelines used and ensuring reports reached relevant store decision makers. This tool may be valuable to support store decision makers in identifying and prioritising nutrition issues and optimising the health-enabling attributes of stores.

Pluripotent, germ cell competent adult stem cells underlie cnidarian regenerative ability and clonal growth.

In most animals, pluripotency is irreversibly lost post gastrulation. By this stage, all embryonic cells have already committed either to one of the somatic lineages (ectoderm, endoderm, or mesoderm) or to the germline. The lack of pluripotent cells in adult life may be linked to organismal aging. Cnidarians (corals and jellyfish) are an early branch of animals that do not succumb to age, but the developmental potential of their adult stem cells remains unclear. Here, we show that adult stem cells in the cnidarian Hydractinia symbiolongicarpus (known as i-cells) are pluripotent. We transplanted single i-cells from transgenic fluorescent donors to wild-type recipients and followed them in vivo in the translucent animals. Single engrafted i-cells self-renewed and contributed to all somatic lineages and gamete production, co-existing with and eventually displacing the allogeneic recipient's cells. Hence, a fully functional, sexually competent individual can derive from a single adult i-cell. Pluripotent i-cells enable regenerative, plant-like clonal growth in these animals.

Communities Setting the Direction for Their Right to Nutritious, Affordable Food: Co-Design of the Remote Food Security Project in Australian Indigenous Communities.

Despite long histories of traditional food security, Indigenous peoples globally are disproportionately exposed to food insecurity. Addressing this imbalance must be a partnership led by Indigenous peoples in accordance with the UN Declaration of the Rights of Indigenous Peoples. We report the co-design process and resulting design of a food security research project in remote Australia and examine how the co-design process considered Indigenous peoples' ways of knowing, being, and doing using the CREATE Tool. Informed by the Research for Impact Tool, together Aboriginal Community Controlled Health Organisation staff, Indigenous and non-Indigenous public health researchers designed the project from 2018-2019, over a series of workshops and through the establishment of research advisory groups. The resulting Remote Food Security Project includes two phases. Phase 1 determines the impact of a healthy food price discount strategy on the diet quality of women and children, and the experience of food (in)security in remote communities in Australia. In Phase 2, community members propose solutions to improve food security and develop a translation plan. Examination with the CREATE Tool showed that employing a co-design process guided by a best practice tool has resulted in a research design that responds to calls for food security in remote Indigenous communities in Australia. The design takes a strengths-based approach consistent with a human rights, social justice, and broader empowerment agenda. Trial registration: The trial included in Phase 1 of this project has been registered with Australian New Zealand Clinical Trials Registry: ACTRN12621000640808.

CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH).

Introduction: Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory. Methods: A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product. Results: COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation. Conclusions: Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.