Consumer perceptions of nutrient content claims in Australia: A qualitative study.

BACKGROUND: Nutrition and health claims influence consumer purchasing. Claims include content claims, which refer to the amount of a nutrient contained in a product, and health claims, which refer to health benefits of foods or nutrients in a product. Products that display a health claim must meet the Nutrient Profiling Scoring Criterion (NPSC). The present study aimed to explore consumer perceptions of content claims used on food and beverage labelling and advertisements. METHODS: Semi-structured focus groups were conducted with Australian consumers. Analysis involved an inductive, reflexive approach to thematic analysis. RESULTS: Six focus groups involving 26 participants were conducted. Four main interconnected themes were generated: (1) complex factors influence food choice; (2) content claim scepticism; (3) the difference between content and health claims is unclear; and (4) the regulation of content claims is not common knowledge. Content claims were used, although generally viewed through a lens of scepticism and mistrust, and seen as a promotional tool for the food industry. Product complexity appeared to increase content claim use as a result of consumer uncertainty of the content of complex products, such as ultraprocessed foods. Most participants were aware that content and health claims were in some way regulated. Overall, they did not know further detail, including the relevant regulatory body. CONCLUSIONS: For content claims to support the consumer they need to be accurate and their use limited to healthier foods. This can be achieved by requiring products with content claims to meet NPSC thresholds, as required for products making health claims.

How healthy are Australian lunch box snacks with child-directed marketing?

ISSUE ADDRESSED: The diets of Australian children, including their lunch boxes have a disproportionate amount of discretionary foods. Packaged snacks have marketing directed to both children and parents. METHODS: Packaged school lunch box snacks were identified on supermarket websites. Nutrition information and child-directed and parent-directed marketing on the package were analysed. The "healthiness" of products was analysed using the Health Star Rating (HSR) (presently on packaging in Australia), two criteria designed for assessing food suitable for marketing to children (the Australian Health Council and the World Health Organization Western Pacific region) and Chilean criteria (used for broad food regulation). RESULTS: The average HSR of the 135 products was 2.2% and 79% had a HSR <3.5. About 39% of products had child-directed marketing. Child-directed marketing would be removed from 89% sweet snacks, and 91% savoury snacks if products with a HSR <3.5 were not allowed to carry that marketing. This is less than the proportion not allowed using criteria from Chile (100%), World Health Organization Western Pacific Region (99%) and the Australian Health Council (93%). CONCLUSIONS: A policy that disallows marketing tactics on unhealthy food based on any of the criteria studied would remove most of both child-directed and parent-directed marketing on packaged lunch box snacks. SO WHAT?: Removing child-directed marketing from unhealthy products would help parents when shopping and contribute to addressing the high proportion of discretionary foods eaten by children at school. Child-directed marketing on packaging should be a part of comprehensive regulation to protect children from the marketing of unhealthy foods.

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.

Changes in nutrition content and health claims post-implementation of regulation in Australia.

OBJECTIVE: To determine whether there were changes in the prevalence or healthiness of products carrying claims post-implementation of Standard 1.2.7: Nutrition, Health and Related Claims in the Australia New Zealand Food Standards Code. DESIGN: Observational survey of claims on food packages in three categories: non-alcoholic beverages, breakfast cereals and cereal bars. Nutrient profiling was applied to products to determine their eligibility to carry health claims under Standard 1.2.7. The Standard came into effect in 2013. The proportion of products carrying claims and the proportion of those not meeting the nutrient profiling criteria were calculated. A comparative analysis was conducted to determine changes between 2011 and 2016. SETTING: Three large metropolitan stores from the three major supermarket chains in Sydney, Australia were surveyed in 2011 and 2016. PARTICIPANTS: All claims on all available products in 2016 (n 1737). Nutrition composition and ingredients were collected from the packaging. RESULTS: Overall in 2016, 76 % of products carried claims and there were 7367 claims identified in the three food categories. Of products in 2016 with health claims, 34 % did not meet nutrient profiling criteria. These may breach Standard 1.2.7. Comparison of 2011-2016 showed a significant increase in the number of products carrying claims (66 v. 76 %, P < 0·001). CONCLUSIONS: The proportion of products carrying claims that do not meet nutrient profiling and consumers' tendency to infer health benefits from nutrition content claims warrants the regulation of all claims using the nutrient profiling. This will ensure consumers are not misled by claims on unhealthy food products.

Nutrient composition of Australian fast-food and fast-casual children's meals available in 2016 and changes in fast-food meals between 2010 and 2016.

OBJECTIVE: A quarter of Australian children are overweight or obese. Research conducted in 2010 found that fast-food children's meals were energy-dense and nutrient-poor. Since then, menu labelling and self-regulation of marketing have been introduced in Australia. The present study aimed to: (i) investigate the nutrient composition of children's meals offered at fast-food chains; (ii) compare these with children's daily requirements and recommendations and the food industry's own criteria for healthier children's meals; and (iii) determine whether results have changed since last investigated in 2010. DESIGN: An audit of nutrition information for fast-food children's meals was conducted. Meals were compared with 30 % (recommended contribution for a meal) and 100 % of children's daily recommendations and requirements. A comparative analysis was conducted to determine if the proportion of meals that exceeded meal requirements and recommendations, and compliance with the food industry's own criteria, changed between 2010 and 2016. SETTING: Large Australian fast-food chains. PARTICIPANTS: All possible children's meal combinations. RESULTS: Overall, 289 children's meals were included. Most exceeded 30 % of daily recommendations and requirements for a 4-year-old's energy, saturated fat, sugars and Na. Results were also substantial for 8- and 13-year-olds, particularly for Na. When compared with mean energy and nutrient contents from 2010, there were minimal changes overall. CONCLUSIONS: Children's meals can provide excess energy, saturated fat, sugar and Na to children's diets. Systematic reformulation of energy, saturated fat, sugars and Na would improve the nutrient composition of the meals.

How effective is food industry self-substantiation of food-health relationships underpinning health claims on food labels in Australia?

OBJECTIVE: The Food Standards Code regulates health claims on Australian food labels. General-level health claims highlight food-health relationships, e.g. 'contains calcium for strong bones'. Food companies making claims must notify Food Standards Australia New Zealand (FSANZ) and certify that a systematic literature review (SLR) substantiating the food-health relationship has been conducted. There is no pre- or post-notification assessment of the SLR, potentially enabling the food industry to make claims based on poor-quality research. The present study assessed the rigour of self-substantiation. DESIGN: Food-health relationships notified to FSANZ were monitored monthly between 2013 and 2017. These relationships were assessed by scoping published literature. Where evidence was equivocal/insufficient, the relevant government food regulatory agency was asked to investigate. If not investigated, or the response was unsatisfactory, the project team conducted an independent SLR which was provided to the government agency. SETTING: Australia.ParticipantsSelf-substantiated food-health relationships. RESULTS: There were sixty-seven relationships notified by thirty-eight food companies. Of these, thirty-three relationships (52 %) from twenty companies were deemed to have sufficient published evidence. Four were excluded as they originated in New Zealand. Three relationships were removed before investigations were initiated. The project initiated twenty-seven food-health relationship investigations. Another six relationships were withdrawn, and three relationships were awaiting government assessment. CONCLUSIONS: To ensure that SLR underpinning food-health relationships are rigorous and reduce regulatory enforcement burden, pre-market approval of food-health relationships should be introduced. This will increase consumer and public health confidence in the regulatory process and prevent potentially misleading general-level health claims on food labels.

Monitoring the changes to the nutrient composition of fast foods following the introduction of menu labelling in New South Wales, Australia: an observational study.

OBJECTIVE: The present study examined the energy (kilojoule) content of Australian fast-food menu items over seven years, before and after introduction of menu board labelling, to determine the impact of the introduction of the legislation. DESIGN: Analysis of the median energy contents per serving and per 100g of fast-food menu items. Change in energy content of menu items across the years surveyed and differences in energy content of standard and limited-time only menu items were analysed. SETTING: Five of Australia's largest fast food chains: Hungry Jack's, KFC, McDonald's, Oporto and Red Rooster. SUBJECTS: All standard and limited-time only menu items available at each fast-food chain, collected annually for seven years, 2009-2015. RESULTS: Although some fast-food chains/menu item categories had significant increases in the energy contents of their menus at some time points during the 7-year period, overall there were no significant or systematic decreases in energy following the introduction of menu labelling (P=0·19 by +17 kJ/100 g, P=0·83 by +8 kJ/serving). Limited-time only items were significantly higher in median energy content per 100 g than standard menu items (+74 kJ/100 g, P=0·002). CONCLUSIONS: While reformulation across the entire Australian fast-food supply has the potential to positively influence population nutrient intake, the introduction of menu labelling legislation in New South Wales, Australia did not lead to reduced energy contents across the five fast-food chains. To encourage widespread reformulation by the fast-food industry and enhance the impact of labelling legislation, the government should work with industry to set targets for reformulation of nutrient content.

Health and nutrition content claims on Australian fast-food websites.

OBJECTIVE: To determine the extent that Australian fast-food websites contain nutrition content and health claims, and whether these claims are compliant with the new provisions of the Australia New Zealand Food Standards Code ('the Code'). DESIGN: Systematic content analysis of all web pages to identify nutrition content and health claims. Nutrition information panels were used to determine whether products with claims met Nutrient Profiling Scoring Criteria (NPSC) and qualifying criteria, and to compare them with the Code to determine compliance. SETTING: Australian websites of forty-four fast-food chains including meals, bakery, ice cream, beverage and salad chains. SUBJECTS: Any products marketed on the websites using health or nutrition content claims. RESULTS: Of the forty-four fast-food websites, twenty (45 %) had at least one claim. A total of 2094 claims were identified on 371 products, including 1515 nutrition content (72 %) and 579 health claims (28 %). Five fast-food products with health (5 %) and 157 products with nutrition content claims (43 %) did not meet the requirements of the Code to allow them to carry such claims. CONCLUSIONS: New provisions in the Code came into effect in January 2016 after a 3-year transition. Food regulatory agencies should review fast-food websites to ensure compliance with the qualifying criteria for nutrition content and health claim regulations. This would prevent consumers from viewing unhealthy foods as healthier choices. Healthy choices could be facilitated by applying NPSC to nutrition content claims. Fast-food chains should be educated on the requirements of the Code regarding claims.

Advertising to children initiatives have not reduced unhealthy food advertising on Australian television.

Background: In response to rising childhood obesity rates, the Australian food industry implemented two initiatives in 2009 to reduce the marketing of unhealthy food to children. This study evaluated the efficacy of these initiatives on the rate of unhealthy food advertising to children on Australian television. Methods: The rates of food advertisements on three free-to-air commercial television channels and a youth-oriented digital channel in Sydney, Australia were analysed over 2 weekdays (16 h) and two weekend days (22 h). Advertisements were categorized according to the healthiness of foods advertised (non-core, core, miscellaneous) and signatory status to the food industry advertising initiatives. Results: Total food advertising rates for the three channels increased from 5.5/h in 2011 to 7.3/h in 2015, due to an increase of 0.8/h for both core and miscellaneous foods. The rate of non-core food advertisements in 2015 (3.1/h) was similar to 2011 (3.0/h). The youth-oriented channel had fewer total food advertisements (3.7/h versus 7.3/h) but similar fast-food advertisement rates (1.3/h versus 1.3/h). Conclusions: There was no change in the rate of unhealthy food advertising since 2011, suggesting minimal impact of the current food industry initiatives on reducing children's exposure to unhealthy food advertising.

Investigating nutrient profiling and Health Star Ratings on core dairy products in Australia.

OBJECTIVE: To determine whether the ratings from the Australian front-of-pack labelling scheme, Health Star Rating (HSR), and the ability to carry health claims using the Nutrient Profiling Scoring Criterion (NPSC) for core dairy products promote foods consistent with the Australian Dietary Guidelines. DESIGN: The Australian nutrient profiling model used for assessing eligibility for health claims was compared with the nutrient profiling model underpinning the HSR system to determine their agreement when assessing dairy products. Agreement between the extent to which products met nutrient profiling criteria and scored three stars or over using the HSR calculator was determined using Cohen's kappa tests. SETTING: The four largest supermarket chains in Sydney, Australia. SUBJECTS: All available products in the milk, hard cheese, soft cheese and yoghurt categories (n 1363) were surveyed in March-May 2014. Nutrition composition and ingredients lists were recorded for each product. RESULTS: There was 'good' agreement between NPSC and HSR overall (κ=0·78; 95 % CI 0·75, 0·81; P<0·001), for hard cheeses (κ=0·72; 95 % CI 0·65, 0·79; P<0·001) and yoghurt (κ=0·79; 95 % CI 0·73, 0·86; P<0·001). There was 'fair' agreement for milk (κ=0·33; 95 % CI 0·20, 0·45; P<0·001) and 'very good' agreement for soft cheese (κ=0·84; 95 % CI 0·75, 0·92; P<0·001). Generally, products tended to have HSR consistent with other products of a similar type within their categories. CONCLUSIONS: For dairy products, the HSR scheme largely aligned with the NPSC used for determining eligibility for health claims. Both systems appeared be consistent with the Australian Dietary Guidelines for dairy products, with lower-fat products rating higher.

Variations in serving sizes of Australian snack foods and confectionery.

This study examined the serving size and energy content per serving of Australian packaged snack foods and confectionery products. Nutrition Information Panel data for 23 sub-categories of packaged snack foods (n = 3481) were extracted from The George Institute for Global Health's 2013 branded food composition database. Variations in serving size and energy content per serving were examined. Energy contents per serving were compared to recommendations in the Australian Dietary Guidelines. Serving sizes varied within and between snack food categories. Mean energy content per serving varied from 320 kJ to 899 kJ. More energy per serving than the recommended 600 kJ was displayed by 22% (n = 539) of snack foods classified in the Australian Dietary Guidelines as discretionary foods. The recommendation for energy content per serving was exceeded in 60% (n = 635) of snack foods from the Five Food Groups. Only 37% (n = 377) of confectionery products displayed the industry-agreed serving size of 25 g. Energy content per serving of many packaged snack foods do not align with the Australian Dietary Guidelines and the industry agreed serving size has not been taken up widely within the confectionery category. Given the inconsistencies in serving sizes, featuring serving size in front-of-pack information may hinder the objective of a clear and simple nutrition message. Messaging to help consumers make healthier choices should consider the variation in serving sizes on packaged snack foods.

Time to address continued poor vegetable intake in Australia for prevention of chronic disease.

BACKGROUND: Australian and most international Dietary Guidelines recommend people consume more fruits and vegetables (F&V) to maintain a healthy weight and reduce chronic disease risk. Previous Australian and international surveys have shown sub-optimal consumption of F&V. OBJECTIVES: This study aimed to assess adults' F&V consumption, knowledge of recommended servings, readiness to change, barriers/enabling factors, so that this knowledge might be used for campaigns that support improved consumption. MATERIAL AND METHODS: An online survey of a representative sample of adults living in New South Wales, Australia (n = 2474) measuring self-reported F&V consumption; attitudes towards F&V consumption; stage of change for increasing F&V; barriers to consumption; and knowledge of cancer-health benefits. RESULTS: F&V consumption was below recommendations, with vegetable consumption notably low. Only 10% of participants ate at least five servings of vegetables/day (median intake was two daily servings), and 57% consumed two servings fruit/day. There was poor recognition that intake of vegetables was inadequate and this was a barrier to improving vegetable consumption; with preferences for other foods, habit and cost also important barriers. Key barriers to increasing fruit intake were habit, preferences for other foods, perishability, and cost. For vegetable consumption, 49% of participants were in the pre-contemplation stage of change, whereas for fruits 56% were in the action/maintenance stage. Sixty-four percent of respondents believed that eating F&V would protect against cancer, with 56% reporting they thought not eating enough F&V would cause cancer. IMPLICATIONS: Understanding what motivates and prevents people from consuming F&V is important for developing effective health promotion programs. Similar to previous surveys, there has been little shift in F&V consumption. Social marketing campaigns have been shown to improve health-related behaviours, and this study may assist in identifying audience segmentation for better targeted campaigns.

Can front-of-pack labelling schemes guide healthier food choices? Australian shoppers' responses to seven labelling formats.

There is evidence that easily accessible, comprehensible and consistent nutrient information on the front of packaged foods could assist shoppers to make healthier food choices. This study used an online questionnaire of 4357 grocery shoppers to examine Australian shoppers' ability to use a range of front-of-pack labels to identify healthier food products. Seven different front-of-pack labelling schemes comprising variants of the Traffic Light labelling scheme and the Percentage Daily Intake scheme, and a star rating scheme, were applied to nine pairs of commonly purchased food products. Participants could also access a nutrition information panel for each product. Participants were able to identify the healthier product in each comparison over 80% of the time using any of the five schemes that provided information on multiple nutrients. No individual scheme performed significantly better in terms of shoppers' ability to determine the healthier product, shopper reliance on the 'back-of-pack' nutrition information panel, and speed of use. The scheme that provided information about energy only and a scheme with limited numerical information of nutrient type or content performed poorly, as did the nutrition information panel alone (control). Further consumer testing is necessary to determine the optimal format and content of an interpretive front-of-pack nutrition labelling scheme.

How well do Australian shoppers understand energy terms on food labels?

OBJECTIVE: To investigate nutrition literacy among adult grocery buyers regarding energy-related labelling terms on food packaging. DESIGN: Qualitative interviews and quantitative surveys to determine shoppers' understanding of energy terms ('energy', 'calories' and 'kilojoules') and how energy terms affect perceptions of healthiness and intentions to purchase breakfast cereals, muesli bars and frozen meals. SETTING: Individual in-depth interviews and surveys in two metropolitan supermarkets, Sydney, Australia. SUBJECTS: Australian adults (interview n 40, survey n 405) aged 18-79 years. RESULTS: The relationship between energy and perceived healthiness of food varied by product type: higher energy breakfast cereals were perceived to be healthier, while lower energy frozen meals were seen as healthier choices. Likewise, intentions to purchase the higher energy product varied according to product type. The primary reason stated for purchasing higher energy products was for sustained energy. Participants from households of lower socio-economic status were significantly more likely to perceive higher energy products as healthier. From the qualitative interviews, participants expressed uncertainty about their understanding of kilojoules, while only 40 % of participants in intercept surveys correctly answered that kilojoules and calories measured the same thing. CONCLUSIONS: Australian consumers have a poor understanding of energy and kilojoules and tend to perceive higher energy products as healthier and providing sustained energy. This has implications regarding the usefulness of industry front-of-pack labelling initiatives and quick service restaurant menu labelling that provides information on energy content only. Comprehensive and widely communicated education campaigns will be essential to guide consumers towards healthier choices.

Comparison of nutrition profiling models for food marketing regulation.

AIM: Regulation on food marketing to children is a recommended response to childhood obesity rates. Policy requires country-relevant criteria to determine which foods are eligible to be advertised. This study aims to compare six nutrition profiling models for use in food marketing regulation in Australia. METHODS: Advertisements on the outside of buses in five suburban Sydney transport hubs were photographed. Food and beverages advertised were analysed using the Health Star Rating; three models developed for food marketing regulation: the Australian Health Council guide and two World Health Organization models; the NOVA system; and the Nutrient Profiling Scoring Criterion used in Australian advertising industry codes. The proportion and types of products advertised on the buses that would be permitted by each of the six models were then analysed. RESULTS: A total of 603 advertisements were identified. Of those, over a quarter of the advertisements were for foods and beverages (n = 157, 26%) and 2.3% (n = 14) for alcohol. Among the food and non-alcoholic beverage advertisements, 84% were for unhealthy foods according to the Health Council guide. The Health Council guide would permit 31% unique foods to be advertised. The NOVA system would permit the least proportion of foods to be advertised (16%), while the Health Star Rating (40%), and Nutrient Profiling Scoring Criterion (38%) would permit the most. CONCLUSION: The Australian Health Council guide is the recommended model for food marketing regulation because it aligns with dietary guidelines by excluding discretionary foods from advertising. Australian governments can use the Health Council guide to develop policy in the National Obesity Strategy to protect children from marketing of unhealthy food.

Perceptions of adequacy of fruit and vegetable intake as a barrier to increasing consumption.

AIM: To investigate New South Wales adults' perceived adequacy of their fruit and vegetable consumption and to identify the barriers to consumption. METHOD: An online cross-sectional survey of a sample of adults in New South Wales (n = 1603) in February 2019 measured self-reported fruit and vegetable intakes, perception of consumption adequacy and barriers to consumption. Proportions of participants whose reported consumption met the daily recommended serves of fruit and vegetables per day were calculated. Chi-square and Fisher's exact tests were used to explore differences between demographic characteristics and meeting fruit and vegetable recommendations. For those not meeting recommendations, Chi-square and Fisher's exact tests were used to explore perceived adequacy of intake as a potential barrier to consumption. RESULTS: The sample included 52.7% women, 40.0% aged under 40 years and 28.6% over 59 years, 68.2% lived in a major city, and 32.6% were university educated. Overall, 64.8% of participants reported consuming adequate fruit and 12.4% reported consuming adequate vegetables. Of those consuming less than the guidelines, 21.3% perceived that they were eating enough fruit and 53.7% perceived they were eating enough vegetables. The most common barriers to eating more fruit were preference for other foods (29.6%), fruit spoiling too quickly (28.3%), and habit (27.0%). The most common barriers to eating more vegetables were the perception that they eat enough (26.8%), preference for other foods (21.9%), and habit (19.7%). CONCLUSIONS: Greater efforts are needed to support the public to eat adequate fruit and vegetables, consistent with dietary guidelines. Public education campaigns specifically targeting increasing vegetable consumption are required to address knowledge gaps, given a large proportion of our study population consumed inadequate levels of vegetables yet perceived their intake to be adequate.

A systematic review of early prognostic factors for persisting pain following acute orthopedic trauma.

BACKGROUND: Acute orthopedic trauma contributes substantially to the global burden of disease. OBJECTIVES: The present systematic review aimed to summarize the current knowledge concerning prognostic factors for the presence of persistent pain, pain severity and pain-related disability following acute orthopedic trauma involving a spectrum of pathologies to working-age adults. METHODS: The Ovid MEDLINE and EMBASE databases were searched for level II prognostic studies published between January 1996 and October 2010. Studies that were longitudinal and reported results with multivariate analyses appropriate for prognostic studies were included. Studies that addressed two specific injury types that have been the subject of previous reviews, namely, injuries to the spinal column and amputations, were excluded. RESULTS: The searches yielded 992 studies; 10 studies met the inclusion criteria and were rated for methodological quality. Seventeen factors were considered in more than one cohort. There was strong evidence supporting the association of female sex, older age, high pain intensity, preinjury anxiety or depression, and fewer years of education with persistent pain outcomes. There was moderate evidence supporting the association between postinjury depression or anxiety with persistent pain, and that injury severity was not a risk factor for ongoing pain. CONCLUSION: Many individuals experience persistent pain following acute trauma. Due to the lack of studies, the use of different constructs to measure the same factor and the methodological limitations associated with many of the studies, the present review was only able to reliably identify a limited set of factors that predicted persistent pain. Recommendations for the conduct of future methodologically rigorous studies of persistent pain are provided.

The association of social functioning, social relationships and the receipt of compensation with time to return to work following unintentional injuries to Victorian workers.

PURPOSE: Understanding individual factors associated with return to work (RTW) post-injury is an important goal of compensation systems research. The aim of the present study was to determine factors associated with time to return to work following acute unintentional injuries. METHODS: A prospective cohort study was conducted in Victoria, Australia. The cohort comprised 133 persons who were employed at the time they were admitted to one of three study hospitals. Baseline health status data was obtained retrospectively at one-week post-injury and participants were further surveyed at 1, 6, 12, 26 and 52 weeks post-injury to measure recovery. Multivariate Cox proportional hazards regression analysis was used to examine the association between potential prognostic factors and time to RTW during the 12 month study. RESULTS: At the end of 12 months follow-up, 81.2% of the study cohort had returned to work. Older age, increased injury severity, self reported symptomatic pain and poor mental health at 1 week post-injury were associated with extended time to RTW. A significant statistical interaction between the receipt of compensation and high social functioning as measured by the SF-36 or strong social relationships as measured by the Assessment of Quality of Life was associated with earlier RTW. Participants reporting strong social relationships and high social functioning at 1 week post-injury and entitled to injury compensation returned to work 2.05 and 3.66 times earlier respectively, than similar participants with no entitlement to compensation. CONCLUSIONS: Both injury-related and psychosocial factors were associated with the duration of time to RTW following acute unintentional injuries. This study replicated previously reported findings on social functioning and compensation from an independent acute trauma sample. Programs or policies to improve social functioning early post-injury may provide opportunities to improve the duration of time to RTW following injury.

Changes in public support for alcohol policies in NSW, Australia, 2013-2019.

OBJECTIVES: Alcohol contributes to significant health, social and economic burdens worldwide, but evidence-based policy options can reduce the harm associated with alcohol use. The aim of this paper is to understand factors influencing public support for various alcohol policies in New South Wales (NSW), Australia, and to determine any change over time. METHODS: An online survey of adults in NSW, in 2013 (n = 2482), 2016 (n = 1585) and 2019 (n = 1601), assessed support for alcohol policies. Multivariable logistic regression models examined the change in support over time, adjusting for demographics, alcohol consumption, smoking status and knowledge of alcohol as a risk factor for cancer. RESULTS: Most participants (68-72%) supported policies preventing underage internet users from exposure to alcohol advertising, and banning alcohol sponsorship of underage music and sporting events. Fiscal policies and restrictions on the number of alcohol outlets were the least supported policies (<40% support). Compared with 2013, participants in 2016 and 2019 were less likely to support policies increasing price, applying a volumetric tax and reducing the number of alcohol outlets. In 2019, more than 55% of respondents were aware that alcohol was a cancer risk factor, and knowledge of that relationship was associated with an increased likelihood of support for alcohol policies. CONCLUSIONS: Support was greatest for alcohol harm-reduction policies that had less impact on an individual's drinking. Overall, support for alcohol policies in NSW is not increasing. Initiatives to raise awareness about the health consequences of alcohol use, together with effective alcohol policies, are needed to counter industry influence on decision makers and negative public discourse.

An ecological study of obesity-related cancer incidence trends in Australia from 1983 to 2017.

Background: Overweight and obesity is a growing public health issue as it contributes to the future burden of obesity-related diseases, including cancer, especially in high-income countries. In Australia, 4.3% of all cancers diagnosed in 2013 were attributable to overweight and obesity. Our aim was to examine Australian age-specific incidence trends over the last 35 years for obesity-related cancers based on expert review (colorectal, liver, gallbladder, pancreas, breast in postmenopausal women, uterine, ovary, kidney, thyroid, and multiple myeloma) individually and pooled. Methods: Australian incidence data for 10 obesity-related cancers among people aged 25-84 years, diagnosed from 1983 to 2017, were obtained from the Australian Cancer Database. We used age-period-cohort modelling and joinpoint analysis to assess trends, estimating incidence rate ratios (IRR) by birth-cohort for each individual cancer and pooled, and the annual percentage change. The analyses were also conducted for non-obesity-related cancers over the same period. Findings: The total number of cancers where some proportion is obesity-related, diagnosed from 1983-2017, was 1,005,933. This grouping was 34.7% of cancers diagnosed. The IRR of obesity-related cancers increased from 0.77 (95% CI 0.73, 0.81) for the 1903 birth-cohort to 2.95 (95% CI 2.58, 3.38) for the recent 1988 cohort relative to the 1943 cohort. The IRRs of non-obesity related cancers were stable with non-significant decreases in younger cohorts. These trends were broadly similar across sex and age groups. Interpretation: The incidence of obesity-related cancers in Australia has increased by birth-cohort across all age-groups, which should be monitored. Obesity, a public health epidemic, needs to be addressed through increased awareness, policy support and evidence-based interventions. Funding: This research received no specific funding.