Factors influencing food service provision decisions in centre-based early childhood education and care services: Cooks' perspective.

ISSUE ADDRESSED: Considerable public effort has been directed at centre-based childcare as an early childhood education and care (ECEC) setting to promote healthy food-related behaviours in young children. However, in the real-world setting, best practice, evidence-based guidelines are not always well-translated into usual, day-to-day routines. This study aims to understand what factors influence the centre-based childcare cooks' food and nutrition decisions for children aged 2-5 years. METHODS: Semi-structured qualitative interviews were conducted with cooks in centre-based childcare using purposeful maximum variation sampling and data analysed thematically. RESULTS: Fourteen cooks were interviewed from 14 services across South Australia. Central to providing a healthy food environment was expert-led knowledge and training gained through the workplace over several years and the embodiment of the service's healthy food and nutrition policy, evidenced through menu planning to maintain a focus on healthy eating. Threatening these positive, routine practices and decisions were pressures to modify menus in response to increasing food allergies and changing cultural and family preferences, in the absence of ongoing relevant training and expertise at the system-level. CONCLUSIONS: Children in ECEC benefit from cooks' commitment to providing nutritious foods; however, the requirements to extend their role to respond to increasing demands without relevant system-level support and training puts the children at risk of not being exposed to health-promoting menus and possible errors in providing dietary modifications. ECEC cooks urgently need access to system-level support and training. SO WHAT?: Understanding and addressing the barriers experienced by cooks and the complexity of factors that inform their food-related decision-making will sustain the implementation of effective, healthy eating guidelines and nutrition practices in ECEC.

A systematic evaluation of digital nutrition promotion websites and apps for supporting parents to influence children's nutrition.

BACKGROUND: Globally children's diet quality is poor. Parents are primary gatekeepers to children's food intake; however, reaching and engaging parents in nutrition promotion can be challenging. With growth in internet and smartphone use, digital platforms provide potential to disseminate information rapidly to many people. The objectives of this review were to conduct a comprehensive and systematic evaluation of nutrition promotion via websites and apps supporting parents to influence children's nutrition, from three different perspectives: 1) current evidence base, 2) end user (parent) experience and 3) current commercial offerings. METHODS: Three systematic reviews were undertaken of (1) studies evaluating the effectiveness for digital platforms for improving nutrition in children and parents, (2) studies conducting user-testing of digital tools with parents, (3) websites and apps providing lunch-provision information to parents. Searches were conducted in five databases for reviews one and two, and systematic search of Google and App Store for review three. Randomised controlled trials, cohort and cross-sectional and qualitative studies (study two only) were included if published in English, from 2013, with the intervention targeted at parents and at least 50% of intervention content focused on nutrition. Search results were double screened, with data extracted into standardised spreadsheets and quality appraisal of included search results. RESULTS: Studies evaluating digital nutrition interventions targeting parents (n = 11) demonstrated effectiveness for improving nutrition outcomes, self-efficacy and knowledge. Six of the included randomised controlled trials reported digital interventions to be equal to, or better than comparison groups. User-testing studies (n = 9) identified that digital platforms should include both informative content and interactive features. Parents wanted evidence-based information from credible sources, practical tools, engaging content and connection with other users and health professionals. Websites targeting lunch provision (n = 15) were developed primarily by credible sources and included information-based content consistent with dietary guidelines and limited interactive features. Lunchbox apps (n = 6), developed mostly by commercial organisations, were more interactive but provided less credible information. CONCLUSIONS: Digital nutrition promotion interventions targeting parents can be effective for improving nutrition-related outcomes in children and parents. As demonstrated from the lunchbox context and user-testing with parents, they need to go beyond just providing information about positive dietary changes, to include the user-desired features supporting interactivity and personalisation.

Treats are a tool of the trade: an exploration of food treats among grandparents who provide informal childcare.

OBJECTIVE: Globally, grandparents are the main informal childcare providers with one-quarter of children aged ≤5 years regularly cared for by grandparents in Australia, the UK and USA. Research is conflicting; many studies claim grandparents provide excessive amounts of discretionary foods (e.g. high in fat/sugar/sodium) while others suggest grandparents can positively influence children's diet behaviours. The present study aimed to explore the meaning and role of food treats among grandparents who provide regular informal care of young grandchildren. DESIGN: Qualitative methodology utilising a grounded theory approach. Data were collected using semi-structured interviews and focus groups, then thematically analysed. SETTING: Participants were recruited through libraries, churches and playgroups in South Australia. PARTICIPANTS: Grandparents (n 12) caring for grandchild/ren aged 1-5 years for 10 h/week or more. RESULTS: Three themes emerged: (i) the functional role of treats (e.g. to reward good behaviour); (ii) grandparent role, responsibility and identity (e.g. the belief that grandparent and parent roles differ); and (iii) the rules regarding food treats (e.g. negotiating differences between own and parental rules). Grandparents favoured core-food over discretionary-food treats. They considered the risks (e.g. dental caries) and rewards (e.g. pleasure) of food treats and balanced their wishes with those of their grandchildren and parents. CONCLUSIONS: Food treats play an important role in the grandparent-grandchild relationship and are used judiciously by grandparents to differentiate their identity and relationship from parents and other family members. This research offers an alternative narrative to the dominant discourse regarding grandparents spoiling grandchildren with excessive amounts of discretionary foods.

Eating occasions and the contribution of foods to sodium and potassium intakes in adults.

OBJECTIVE: To examine dietary Na and K intake at eating occasions in Australian adults and identify the contribution of major food sources to Na and K at different eating occasions. DESIGN: Secondary analysis of 24 h recall diet data from the Australian Health Survey (2011-2013). SETTING: Nationally representative survey in Australia. SUBJECTS: Male and female Australians aged 18-84 years (n 7818). RESULTS: Dinner contributed the greatest proportion to total daily Na intake (33 %) and K intake (35 %). Na density was highest at lunch (380 mg/MJ) and K density highest at between-meal time eating occasions (401 mg/MJ). Between-meal time eating occasions provided 20 % of daily Na intake and 26 % of daily K intake. The major food group sources of Na were different at meal times (breads and mixed dishes) compared with between-meal times (cakes, muffins, scones, cake-type desserts). The top food group sources of K at meal times were potatoes and unprocessed meat products and dishes. CONCLUSIONS: Foods which contributed to Na and K intake differed according to eating occasion. Major food sources of Na were bread and processed foods. Major food sources of K were potatoes and meat products and dishes. Public health messages that emphasise meal-based advice and diet patterns high in vegetables, fruits and unprocessed foods may also aid reduction in dietary Na intake and increase in dietary K intake.

Does the presence of cardiovascular disease risk factors or established disease influence the dietary intake of affected adults and their children residing in the same household? A secondary analysis of the Australian Health Survey (2011-2013).

BACKGROUND: Diet is an important contributor to risk of cardiovascular disease (CVD) and integral in management and delaying progression. Little is known however about whether increased CVD risk or established CVD has any influence on dietary intakes of Australian adults or children residing in the same household. This study aimed to determine whether the presence of CVD or CVD risk factors influences dietary intake of Australian adults and if the presence of an adult with increased CVD risk influences the dietary intake of a child living in the same household. METHODS: Data were sourced from the 2011-2013 Australian Health Survey for: (1) adults ≥18 years with risk factors or established CVD and (2) children 2-17 years residing in the same household as adults with CVD risk factors or established CVD. Selected nutrient intakes (total fat, saturated fat plus trans fat, alpha-linolenic acid, total long chain omega 3 fatty acids, fibre and sodium) collected by repeated 24 h recalls were compared to national dietary recommendations and to the intakes of all other adults and children surveyed. Standard errors of the estimates were calculated using the replicate weights method, and an alpha value of <0.05 considered statistically significant. RESULTS: Six thousand two hundred sixty five of 9435 adults surveyed were identified as having CVD risk factors or established disease and of these 1609 had a child in the same household that also contributed data in this survey. No differences were observed in adjusted mean dietary intakes between those without risk factors or established CVD and those with, except for total energy and sodium which were significantly lower in the adults with CVD risk factors and/or established disease. However sodium intakes across both groups were higher than recommended targets. There were no differences for selected nutrients between children residing with affected adults and other children surveyed. CONCLUSIONS: While intakes of Australian adults with CVD risk factors or established disease were favourable for sodium, compared to unaffected adults, there is still scope for improvement as many Australian adults, despite CVD risk, are unable to achieve targets for selected nutrients. Effective dietary behaviour change strategies and resources are urgently needed.

Engaging South Australian local governments in the development of healthy eating policies.

Issue addressed Local governments are uniquely placed to influence the food environment of their communities through healthy eating policies (HEPs) but very few have done so. Methods Using a community-based participatory approach, Healthy Eating Local Policies and Programs built the capacity of South Australian local governments to develop and implement a HEP by leading the development of a HEP framework then mentoring local governments to develop their own local policy tailored to their community. Results Over a 2-year period, 31 of the 68 local governments worked towards developing a HEP, with 14 receiving endorsement by December 2013. Conclusions Local governments are ready to model healthy eating practices and adopt healthy eating policy that supports the health of their communities. A HEP developed using a participatory approach and with the flexibility to be tailored to local preferences and demographics appears feasible, although the process may be lengthy. This process and outcome appears applicable and transferable to other local governments. So what? As local governments take up their responsibilities in promoting health and wellbeing, HEPs provide important structural mechanisms to enable councils to facilitate healthy eating in their local communities.

Dietary intake of working women with children does not appear to be influenced by hours of employment: A secondary analysis of the Australian Health Survey (2011-2013).

UNLABELLED: Women with children often fulfil multiple roles of running a household, raising a family and working outside the home. Good nutrition during this time is important to optimise their performance and prevent lifestyle diseases. Women also act as nutritional gatekeepers for their family. The dual burden of paid employment and unpaid family work may be associated with time scarcity in mothers which can impact food preparation and therefore nutritional adequacy. The aim of this study was to examine the diet of women who lived with children by comparison of hours worked. METHODS: This was a secondary analysis of the Australian National Nutrition and Physical Activity Survey 2011-12. Subjects were women aged 18-65 years who resided with ≥1 child (<18 years). Women were grouped according to hours of employment: not working; working <25 h a week; and working ≥25 hours a week. Data from two 24-h dietary recalls were used to compare differences between groups in nutrient intake and proportion of energy from discretionary foods. Covariates included were age, education, smoker status, Socio-Economic Indexes for Areas (SEIFA), number of persons in household, week or weekend day of the survey and the sequence of recalls. RESULTS: Analyses included 1869 women. Dietary intakes varied minimally between groups with intakes of fibre, vitamin C, and calcium lowest in the group not working. Overall diet quality was poor with >30% of energy coming from discretionary foods in all groups. CONCLUSIONS: Usual hours of employment per week have a minimal effect on diet quality in women with children. It is likely that different factors specific to each group contribute to the poor dietary intakes and should be further investigated.

Interprofessional education within a nurse practitioner led paediatric service: A multi-methods study.

AIM: This project explored whether a nurse practitioner led mobile paediatric screening service in early learning centres could incorporate allied health and nursing students and develop their confidence in interprofessional collaboration. BACKGROUND: Interprofessional collaboration is essential for health professionals across all contexts of care, including early childhood screening and intervention that enables children to thrive. METHODS: This multi-methods study (pre-test/post-test design) was conducted with nursing, physiotherapy, occupational therapy and nutrition and dietetics students attending clinical placement within the nurse practitioner led mobile paediatric service. Data were collected via pre and post placement surveys (ISVS-21) and post placement semi-structured interviews. RESULTS: Twelve students participated from July to December 2022. Survey findings demonstrated students improved inter-professional socialisation and readiness, supported by qualitative findings that uncovered unique mechanisms for how positive experiences were achieved. Unique pedagogical elements included 1) the nurse practitioner's professional attributes and 2) the mobile nature of the service leveraging learning opportunities within the shared commute. CONCLUSIONS: This study provides proof-of-concept of a placement model that facilitates interprofessional collaboration in nursing and allied health students. Further research should explore longer-term outcomes and scalability.

Determining Dietary Patterns to Recommend for Type 2 Diabetes: An Umbrella Review.

Some specific dietary patterns improve glycaemic levels and cardiovascular risk factors better than others. We aimed to identify the most effective dietary patterns using a food-focused approach to improve blood glucose management (primary outcome) and cardiovascular risk factors (secondary outcome) in people with type 2 diabetes. An umbrella review was conducted comparing dietary patterns for the management of these outcomes. Studies published between 2012 and 2022 were identified using PubMed Central, ProQuest, Web of Science, and the Cochrane Database of Systematic Reviews. Thirty systematic reviews met the inclusion criteria. Twenty-two of thirty reviews quantitated (via meta-analyses of over 212 randomised control trials) the effect size of different dietary patterns. Twelve reviews found Low-carbohydrate (LC), Mediterranean (M), Plant-based (PB), and/or Low-glycaemic Index (LGI) diets reduced HbA1c moderately more than control diets (typically a high-carbohydrate, low-fat diet) (i.e., LC: -0.1 to -0.5%; M: -0.3 to -0.5%; PB: -0.2 to -0.4%; LGI -0.2 to -0.5%; all p-value < 0.01). We conclude that Low-carbohydrate, Mediterranean, Plant-based, and Low-glycaemic Index dietary patterns are all clinically effective for people with type 2 diabetes as alternatives to high-carbohydrate, low-fat diets typically used for managing glycaemic levels and CVD risk. However, quality evidence about the sustainability of effects and safety remains limited, warranting future research.

Food acculturation experiences of new Iranian skilled migrant mothers in South Australia.

AIM: This research aimed to investigate the food acculturation experiences of Iranian mothers who have migrated to Australia. METHODS: The study used qualitative methodology to interview seven mothers with children aged 5 to 15 years, who: carried primary responsibility for family food provisioning; arrived in Australia within the last 5 years; and spoke reasonably fluent English. RESULTS: Seven mothers were interviewed, and the findings revealed three broad themes: (a) adjusting to foods/foodways in Australia (b) sociocultural identity and (c) children and intergenerational conflict. The study highlighted psychosocial and economic stresses associated with food acculturation for this immigrant group. The impact of food acculturation on immigrant health is intricately linked to the complex balance between maintaining traditional cultural identity and practices, while at the same time adapting to the food culture and practices of the new home. CONCLUSIONS: Dietitians and healthcare professionals working with such immigrant groups need to consider food acculturation stress as a factor contributing to the health risks of new immigrants.

An Overview of Research Opportunities to Increase the Impact of Nutrition Intervention Research in Early Childhood and Education Care Settings According to the RE-AIM Framework.

Objective: To highlight opportunities for future nutrition intervention research within early childhood and education care (ECEC) settings, with a focus on generating evidence that has applicability to real-world policy and practice. Methods: An overview of opportunities to progress the field was developed by the authors using a collaborative writing approach and informed by recent research in the field. The group developed a list of recommendations aligned with the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Pairs of authors drafted individual sections of the manuscript, which were then reviewed by a separate pair. The first and senior author consolidated all sections of the manuscript and sought critical input on the draft iterations of the manuscript. Results: Interventions that employ digital platforms (reach) in ECEC settings, as well as research in the family day care setting (effectiveness) were identified as areas of opportunities. Research understanding the determinants of and effective strategies for dissemination (adoption), the implementation of nutrition programs, in addition to de-implementation (implementation) of inappropriate nutrition practices, is warranted. For maintenance, there is a need to better understand sustainability and the sustainment of interventions, in addition to undertaking policy-relevant research. Conclusions: The ECEC setting is prime for innovative and practical nutrition intervention research.

Childcare Food Provision Recommendations Vary across Australia: Jurisdictional Comparison and Nutrition Expert Perspectives.

Early childhood is a critical stage for nutrition promotion, and childcare settings have the potential for wide-reaching impact on food intake. There are currently no Australian national guidelines for childcare food provision, and the comparability of existing guidelines across jurisdictions is unknown. This project aimed to map and compare childcare food provision guidelines and to explore perspectives amongst early childhood nutrition experts for alignment of jurisdictional childcare food provision guidelines with the Australian Dietary Guidelines (ADG). A desktop review was conducted and formed the basis of an online survey. A national convenience sample of childhood nutrition experts was surveyed. Existing guideline recommendations for food group serving quantities were similar across jurisdictions but contained many minor differences. Of the 49 survey respondents, most (84-100%) agreed with aligning food group provision recommendations to provide at least 50% of the recommended ADG serves for children. Most (94%) agreed that discretionary foods should be offered less than once per month or never. Jurisdictional childcare food provision guidelines do not currently align, raising challenges for national accreditation and the provision of support and resources for services across jurisdictions. Childhood nutrition experts support national alignment of food provision guidelines with the ADG.

The role of dietitians in residential aged care: How do cooks and chefs perceive their contribution?

OBJECTIVE: This study aimed to explore how dietitians could work with cooks and chefs to contribute to best practice. METHODS: Data from interviews and focus groups comprising 38 chefs, cooks and food service managers were analysed. Inductive line-by-line coding of transcripts was conducted within a critical realist framework. Coding was completed independently by two authors before reaching consensus on themes. RESULTS: Four main themes emerged: (i) knowledge sharing; (ii) communication; (iii) collaboration; and (iv) accessibility. Participants praised dietitians' knowledge and expertise, but some raised concerns about inconsistency in the advice they received. CONCLUSION: Dietitians working in residential aged care are ideally positioned to act as advocates for residents and food services. However, findings suggest that experiences of working with dietitians are mixed. Aged care menu guidelines and quality measures could assist, not only in promoting a consistent approach to dietetic advice, but also a system for benchmarking satisfaction and best practice.

Feasibility of a Group-Based, Facilitator-Directed Online Family Lifestyle Program.

OBJECTIVE: This study aimed to overcome barriers to access and attendance, and improve recruitment and engagement, through delivery and evaluation of the Parenting, Eating and Activity for Child Health (PEACH) child weight management program, as a facilitated group-based online healthy lifestyle program, PEACH Lifestyle. METHODS: Pre-post feasibility study of an online intervention comprising a website with 10 self-directed learning modules and 6 facilitated group-based video conferencing sessions with parents (n = 79) of children (7.9 ± 2.9 years, 25% healthy weight, 23% obese). RESULTS: Three enrollees were from remote locations. Half of the parents (n = 38) attended ≥1 video conferencing session (median = 3 participants per session [Range, 0-7]). Thirty percent (n = 7 of 21) completed all 10 online modules. Technical issues, time, and family commitments were barriers to engagement. CONCLUSIONS AND IMPLICATIONS: Reframing and delivering a weight management program as a healthy lifestyle program online in real-time did not address barriers to engagement in PEACH Lifestyle.

Characteristics of Effective Interventions Promoting Healthy Eating for Pre-Schoolers in Childcare Settings: An Umbrella Review.

Early Childhood Education and Care (ECEC) settings have a pivotal role in shaping children's dietary food habits by providing the contextual environment within which they develop these behaviours. This study examines systematic reviews for (1) the effectiveness of interventions to promote healthy eating in children aged 2-5 years attending centre-based childcare; (2) intervention characteristics which are associated with promoting healthy eating and; (3) recommendations for child-health policies and practices. An Umbrella review of systematic reviews was undertaken using a standardized search strategy in ten databases. Twelve systematic reviews were examined using validated critical appraisal and data extraction tools. Children's dietary food intake and food choices were significantly influenced. Interventions to prevent obesity did not significantly change children's anthropometric measures or had mixed results. Evidence was more convincing if interventions were multi-component, addressed physical activity and diet, targeted individual-level and environmental-level determinants and engaged parents. Positive outcomes were mostly facilitated by researchers/external experts and these results were not replicated when implemented in centres by ECEC providers without this support. The translation of expert-led interventions into practice warrants further exploration of implementation drivers and barriers. Based on the evidence reviewed, recommendations are made to inform child-health directed practices and policies.

Engaging food service providers to change food service practices in aged care facilities.

AIM: The present study describes the impact of a novel education program for food service staff from Australian aged care facilities (ACF) to facilitate improvements in food service practices. The purpose was to explore; (i) the impact of the intervention (ii) barriers and facilitators of the program from food service providers' perspectives and (iii) make program planning and practice recommendations. METHODS: Participants completed pre- and post-program questionnaires, attended two focus groups on program process and impact and 4 months later reported through individual interviews on changes they had implemented. Results were triangulated between the questionnaires, focus groups and interviews and impacts and outcomes identified through directed content analysis. RESULTS: Thirty senior-level chefs and a cook participated from 27 ACF from Victoria, Australia. Participation impacted on the menu, dining experiences and food service practices. All of the participants were enacting changes in their workplace 4 months later as change agents. A focus on skilling the participants as 'change agents', brokering ongoing peer-support and the celebrity and/or expert status of the facilitators were attributed to the success of the intervention. CONCLUSIONS: This novel intervention empowered Victorian food service providers to make positive changes in ACF. Further research is required to measure if these self-reported changes are sustainable and relevant to other facilities and to establish the effect on food experience, satisfaction and well-being of residents.

An evaluation of a nutrition intervention at childcare centres in South Australia.

ISSUE ADDRESSED: Research has shown that childcare menus in South Australia, Australia and overseas lack key nutrients recommended for children. This paper describes an incentive initiative that aimed to improve the nutrition provided to children attending childcare centres in the southern metropolitan area of South Australia between 2001 and 2003. METHODS: To attain the 'Start Right Eat Right' award, aimed at childcare centres, directors and cooks from 50 centres were required to attend training, analyse a current menu for quality and quantity against various tools, review their food policy for essential criteria, have two site visits and have all staff trained in a recognised food safety and hygiene program. RESULTS: Forty-four (88%) of the centres completed training. Qualitative feedback from 10 awarded centres reported substantial changes and their food policy analysis showed an increase of essential points from an average score of 8.4 to 17.1 (max. score 18). More than 300 staff completed food hygiene training. Fifty per cent of the eligible centres had completed the award at program evaluation. CONCLUSION: This multi-strategic intervention was effective in improving the food provided and nutrition practices in childcare settings. Strategies attributed to its success were an inter-sectoral approach and the creation of supportive environments.