Older adults' needs and preferences for a nutrition education digital health solution: A participatory design study.

BACKGROUND: The global population is ageing rapidly and there is a need for strategies to promote health and wellbeing among older adults. Nutrition knowledge is a key predictor of dietary intake; therefore, effective educational programmes are urgently required to rectify poor dietary patterns. Digital health technologies provide a viable option for delivering nutrition education that is cost-effective and widely accessible. However, few technologies have been developed to meet the unique needs and preferences of older adults. OBJECTIVE: The aim of this study was to explore technology use among older adults and qualitatively determine the content needs and design preferences for an online nutrition education resource tailored to older adult consumers in Australia. METHODS: Twenty adult participants aged 55 years and older (95% female) participated in one of four 2-h participatory design workshops. In each workshop, prompted discussion questions were used to explore participants' technology use and preferences and to explore content needs and design preferences for an online nutrition education resource specific to older adults. RESULTS: All participants were regularly using a range of different devices (e.g., smartphones, tablets and computers) and reported being comfortable doing so. Participants wanted a website that provided general nutrition information, practical advice and recipes. To enhance engagement, they sought a personalised resource that could be adjusted to suit their needs, included up-to-date information and allowed for easy sharing with others by exporting information as a PDF. CONCLUSIONS: Participatory design methods generate new knowledge for designing and tailoring digital health technologies to be appropriate and useful for the target audience. Specifically, older adults seek an online resource that has large and simple fonts with clear categories, providing them with practical advice and general nutrition information that can be personalised to suit their own needs and health concerns, with the option to export and print information into a paper-based format. PATIENT OR PUBLIC CONTRIBUTION: Older adults actively participated in the development and evaluation process to generate ideas about potential features, functionalities, uses and practicalities of an online nutrition education resource.

Genetic and environmental influences on fruit and vegetable consumption and depression in older adults.

BACKGROUND: Prior work suggests that higher fruit and vegetable consumption may protect against depression in older adults. Better understanding of the influence of genetic and environmental factors on fruit and vegetable intakes may lead to the design of more effective dietary strategies to increase intakes. In turn this may reduce the occurrence of depression in older adults. OBJECTIVES: The primary aim of this study is to estimate the genetic and environmental influences on the consumption of fruit and vegetables in older adults. The secondary aim is an exploratory analysis into possible shared genetic influences on fruit and vegetable intakes and depression. METHODS: Analysis of observational data from 374 twins (67.1% female; 208 monozygotic (MZ); 166 dizygotic (DZ)) aged ≥ 65 years drawn from the Older Australian Twins Study. Dietary data were obtained using a validated food frequency questionnaire and depressive symptoms were measured using the 15-item short form Geriatric Depression Scale. The contribution of genetic and environmental influences on fruit and vegetable intake were estimated by comparing MZ and DZ twin intakes using structural equation modelling. A tri-variate twin model was used to estimate the genetic and environmental correlation between total fruit and vegetable intakes and depression. RESULTS: In this study, vegetable intake was moderately influenced by genetics (0.39 95%CI 0.22, 0.54). Heritability was highest for brassica vegetables (0.40 95%CI 0.24, 0.54). Overall fruit intake was not significantly heritable. No significant genetic correlations were detected between fruit and vegetable intake and depressive symptoms. CONCLUSIONS: Vegetable consumption, particularly bitter tasting brassica vegetables, was significantly influenced by genetics, although environmental influences were also apparent. Consumption of fruit was only influenced by the environment, with no genetic influence detected, suggesting strategies targeting the food environment may be particularly effective for encouraging fruit consumption.

Knowledge, Attitudes, and Behaviours Concerning the Mediterranean Diet Among Older Adults in Australia.

Despite the growing body of evidence demonstrating the positive health effects of the Mediterranean diet, it is not routinely recommended in practice and adherence is low in the general population in Australia. The knowledge-attitude-behaviour model explains how health behaviours are supported through a process of acquiring knowledge, developing attitudes, and forming behaviours. Evidence has suggested that having a high level of nutrition-related knowledge is associated with more positive attitudes, which is directly linked to positive dietary behaviours. However, reports of knowledge and attitudes towards the Mediterranean diet, and how these directly relate to behaviours in older adults, are lacking. This study explored Mediterranean diet-related knowledge, attitudes, and behaviours among community-dwelling older adults in Australia. Participants were adults aged 55 years and older who completed an online survey that contained three parts: (a) knowledge - Mediterranean Diet Nutrition Knowledge Questionnaire (Med-NKQ); (b) nutrition-related attitudes and behaviours, and barriers and enablers to dietary change; (c) demographics. The sample included 61 adults who ranged in age from 55 to 89 years. The overall knowledge score was 30.5 out of a possible 40 points, with 60.7% classified as having a high level of knowledge. Knowledge was lowest for nutrient content and label reading. Attitudes and behaviours were generally positive and were not associated with level of knowledge. The most common barriers to dietary change were perceived cost and lack of knowledge, and motivational factors. There are a number of key gaps in knowledge that should be addressed through targeted educational programs. Strategies and tools to overcome perceived barriers and improve self-efficacy are needed to facilitate positive dietary behaviours.

Why do some people with osteoarthritis and obesity awaiting hip or knee arthroplasty achieve successful weight management? A qualitative study.

AIM: To explore perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. DESIGN: A nested qualitative study within a multi-centre, quasi-experimental pilot study comparing usual care weight management to a dietitian-led weight-loss diet. METHODS: Semi-structured individual interviews were conducted with adults with end-stage osteoarthritis and a body mass index ≥30 kg/m2 waitlisted for primary total knee or hip arthroplasty. Participants with diverse sociodemographic characteristics and varied success with weight management in the pilot study were purposively sampled. Interviews were analysed using inductive thematic analysis, underpinned by constructivist-interpretivist epistemology. The Patient Activation Measure and Health Literacy Questionnaire were used for context when interpreting the findings. RESULTS: Twenty-five participant interviews were conducted with a sociodemographically varied sample (aged 44-80 years, 9 born in Australia, 6 in paid employment and 11 lost ≥5% of their baseline weight). Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Adaptability, the ability to overcome barriers to weight loss, comprised three subthemes; readiness to act, degree of independence and problem-solving skills. Approaches towards navigating healthcare influenced uptake and adherence to weight management recommendations. Importantly, these themes were dependent on social and environmental circumstances, which influenced the type of barriers experienced and resources available to the individual. CONCLUSION: Differences in a person's beliefs, their ability to adapt and navigate healthcare and sociocultural context appear to explain successful weight management among people with end-stage arthritis. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Clinicians should allow for individualisation cognisant of the identified themes when providing advice and treatment to promote adherence to weight management interventions. IMPACT: This study explored perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Understanding and assessing the contribution of each factor may guide weight management from clinicians treating patients with obesity and osteoarthritis. REPORTING METHOD: The data are reported using the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients contributed to the data collected.

Nutrition Module design in Maintain Your Brain: an internet-based randomised controlled trial to prevent cognitive decline and dementia.

The Maintain Your Brain (MYB) trial is one of the largest internet-delivered multidomain randomised controlled trial designed to target modifiable risk factors for dementia. It comprises four intervention modules: physical activity, nutrition, mental health and cognitive training. This paper explains the MYB Nutrition Module, which is a fully online intervention promoting the adoption of the 'traditional' Mediterranean Diet (MedDiet) pattern for those participants reporting dietary intake that does not indicate adherence to a Mediterranean-type cuisine or those who have chronic diseases/risk factors for dementia known to benefit from this type of diet. Participants who were eligible for the Nutrition Module were assigned to one of the three diet streams: Main, Malnutrition and Alcohol group, according to their medical history and adherence to the MedDiet at baseline. A short dietary questionnaire was administered weekly during the first 10 weeks and then monthly during the 3-year follow-up to monitor whether participants adopted or maintained the MedDiet pattern during the intervention. As the Nutrition Module is a fully online intervention, resources that promoted self-efficacy, self-management and process of change were important elements to be included in the module development. The Nutrition Module is unique in that it is able to individualise the dietary advice according to both the medical and dietary history of each participant; the results from this unique intervention will contribute substantively to the evidence that links the Mediterranean-type diet with cognitive function and the prevention of dementia and will increase our understanding of the benefits of a MedDiet in a Western country.

Assessing health literacy among adult outpatients attending allied health clinics in western sydney: A cross-sectional survey using a multidimensional instrument.

ISSUE ADDRESSED: Low health literacy disproportionately affects adults from culturally and linguistically diverse backgrounds. This study investigated the health literacy of adults attending outpatient allied health services in western Sydney, a highly diverse region in Sydney with residents from a range of cultural and linguistic backgrounds. METHODS: A cross-sectional survey was undertaken between March and April 2017 using the Health Literacy Questionnaire (HLQ). Participants, aged over 18 years and with a primary language of English, Arabic, Chinese or Hindi, were recruited from outpatient allied health clinics at Westmead Hospital. Means (standard deviation) for each of the nine HLQ domains were calculated and associations with demographic variables were investigated using analysis of variance (ANOVA). RESULTS: Two hundred and thirty people were included with mean age of 45.1 years (SD = 19.0), the majority were female (75.5%), over half were born overseas (55.7%) and 77.6% reported speaking English at home. The highest mean score on a HLQ domain (out of 5) was "Understanding health information well enough to know what to do" (M = 4.19; SD = 0.67), and the lowest mean score (out of 4) was "Appraisal of health information" (M = 2.97; SD = 0.54). Participants who did not speak English at home had significantly lower scores on seven of the nine HLQ domains. CONCLUSIONS: Important health literacy strengths and limitations of a diverse sample of adults attending outpatient allied health services in western Sydney were identified. Findings should be considered in the light of the cross-sectional survey methodology with non-random sampling. SO WHAT: Data will inform future interventions to improve health literacy and health outcomes among vulnerable population groups in western Sydney.

Vitamin C improves healing of foot ulcers: a randomised, double-blind, placebo-controlled trial.

Chronic foot ulcers are associated with a high risk of osteomyelitis, poor quality of life, amputations and disability. Few strategies improve their healing, and amputation rates in high-risk foot services are usually over 30 %. We conducted a randomised, inactive-placebo controlled, double-blind trial of 500 mg of slow-release vitamin C in sixteen people with foot ulcers in the Foot Wound Clinic at Westmead Hospital. Nine were randomised to control and seven to vitamin C. When serum vitamin C results become available at 4 weeks, all people with deficiency were offered both vitamin C and glucosamine tablets for the next 4 weeks. Patients without baseline deficiency continued their original assigned treatment. The primary outcome was percentage ulcer healing (reduction in ulcer size) at 8 weeks. Fifty percentage of subjects had baseline vitamin C deficiency, half having undetectable levels. Healing at 8 weeks was significantly better in the vitamin C group (median 100 v. -14 %, P = 0·041). Healing without amputation occurred in all patients in the vitamin C group. In contrast, 44 % of controls had not healed their ulcer at the end of the study period. Vitamin C improved healing of foot ulcers. Further studies are needed to determine whether there is a threshold effect for serum vitamin C above which therapy is ineffective and whether there are better or lesser responding subgroups. Because of its low cost and ease of access and administration, we recommend offering vitamin C therapy to all people who have chronic foot ulcers and potentially suboptimal vitamin C intake. Trial registration number: ACTRN12617001142325.

Relative validity and reliability of a novel diet quality assessment tool for athletes: the Athlete Diet Index.

Diet quality indices are a practical, cost-effective method to evaluate dietary patterns, yet few have investigated diet quality in athletes. This study describes the relative validity and reliability of the recently developed Athlete Diet Index (ADI). Participants completed the electronic ADI on two occasions, 2 weeks apart, followed by a 4-d estimated food record (4-dFR). Relative validity was evaluated by directly comparing mean scores of the two administrations (mAdm) against scores derived from 4-dFR using Spearman's rank correlation coefficient and Bland-Altman (B-A) plots. Construct validity was investigated by comparing mAdm scores and 4-dFR-derived nutrient intakes using Spearman's coefficient and independent t test. Test-retest reliability was assessed using paired t test, intraclass correlation coefficients (ICC) and B-A plots. Sixty-eight elite athletes (18·8 (sd 4·2) years) from an Australian sporting institute completed the ADI on both occasions. Mean score was 84·1 (sd 15·2; range 42·5-114·0). The ADI had good reliability (ICC = 0·80, 95 % CI 0·69, 0·87; P < 0·001), and B-A plots (mean 1·9; level of agreement -17·8, 21·7) showed no indication of systematic bias (y = 4·57-0·03 × x) (95 % CI -0·2, 0·1; P = 0·70). Relative validity was evaluated in fifty athletes who completed all study phases. Comparison of mAdm scores with 4-dFR-derived scores was moderate (rs 0·69; P < 0·001) with no systematic bias between methods of measurement (y = 6·90-0·04 × x) (95 % CI -0·3, 0·2; P = 0·73). Higher scores were associated with higher absolute nutrient intake consistent with a healthy dietary pattern. The ADI is a reliable tool with moderate validity, demonstrating its potential for application to investigate the diet quality of athletes.

The Platform to Evaluate Athlete Knowledge of Sports Nutrition Questionnaire: a reliable and valid electronic sports nutrition knowledge questionnaire for athletes.

Reliable and valid assessment of sports nutrition knowledge can inform athlete nutrition education to address knowledge gaps. This study aimed to test the reliability and validity of an electronically administered sports nutrition knowledge tool - Platform to Evaluate Athlete Knowledge of Sports Nutrition Questionnaire (PEAKS-NQ). A 94-item PEAKS-NQ was piloted to 149 developmental athletes (DA) in New Zealand, with a subset invited to complete the PEAKS-NQ again to assess reliability. Reliability was evaluated using sign test, intraclass correlation and Cronbach's α. Accredited sports dietitians (ASD; n 255) completed the PEAKS-NQ to establish construct validity via known-groups methodology and provided relevance scores to determine the scale content validity index (S-CVI). Rasch analysis was conducted to identify potentially problematic items and test reliability. Score differences between DA and ASD were analysed using independent t or non-parametric tests. DA (n 88) were 17·8 (sd 1·4) years, 61·4 % female and mostly in high school (94·3 %). ASD (n 45) were 37·8 (sd 7·6) years, 82·2 % female, with >5 years of dietetic experience (59·1 %). ASD scored higher than DA in all sections and overall (91·5 (sd 3·4) v. 67·1 (sd 10·5) %) (P < 0·001). There were no differences between retests (n 18; P = 0·14). Cronbach's α was 0·86. S-CVI indicated good content validity (0·88). Rasch analysis resulted in a fifty-item PEAKS-NQ with high item (0·91) and person (0·92) reliability. The PEAKS-NQ is reliable and valid for assessing sports nutrition knowledge which could assist practitioners effectively tailor and evaluate nutrition education.

Evaluation of educational interventions on eye health for dietetic and pharmacy professions: a pre-post study.

BACKGROUND: We piloted an educational intervention that aimed to enhance awareness about nutrition-age-related macular degeneration (AMD) links among practising and student dietitians then expanded the scope of this intervention to include general eye health, which was delivered to pharmacy students. METHODS: A pilot intervention was conducted in 2019 at the Dietitians Australia Conference (Gold Coast, Australia) where practising and student dietitians underwent a 2-hour small group educational workshop on nutrition and AMD links. Pre-post questionnaires were administered to participants, with voluntary completion of both questionnaires an indicator of consent to participate in the intervention. The primary intervention outcome was a change in AMD-related nutrition knowledge pre-post intervention. A larger intervention was then conducted at the University of Sydney (Sydney, Australia) where pharmacy students underwent a 4-hour educational module to improve general eye health knowledge, as well as student perceptions and attitudes towards a pharmacists' role in low vision care. Similarly, pre-post questionnaires were administered, with voluntary completion of both questionnaires an indicator of consent to participate in the intervention. The primary intervention outcomes were changes in total knowledge, total perception and total attitude scores pre-post intervention. RESULTS: (1) Among 10 accredited and 5 student dietitians, there was significant overall knowledge improvement (mean pre-post score: 7.07 ± 1.94 vs. 10.8 ± 1.01, p = 0.001) specifically around appropriate dietary advice, food sources of key AMD-related nutrients, and awareness of supplements. (2) Among 179 second-year pharmacy students enrolled in the 'Pharmacy Practice' Unit of Study (Bachelor of Pharmacy, University of Sydney), total eye health knowledge (6.25 ± 1.93 vs. 6.64 ± 2.0; p = 0.011) significantly improved, along with total perception scores (41.54 ± 5.26 vs. 42.45 ± 4.95; p = 0.004). Total attitude scores were not significantly different. CONCLUSIONS: The pilot intervention improved relevant nutrition-AMD knowledge among practising/student dietitians. The modified intervention for pharmacy students also significantly improved general eye health knowledge as well as students' perception of a pharmacists' role in low vision care.

Development and evaluation of a health literacy training program for allied health professionals: A pre-post study assessing impact and implementation outcomes.

ISSUE ADDRESSED: We developed and evaluated a health literacy training program for allied health professionals, and explored the feasibility of a train-the-trainer model to support dissemination. METHODS: The program combined didactic and experiential teaching methods and behaviour change techniques, with a focus on teach-back and developing easy-to-understand written materials. Outcomes included participant reactions, confidence (range: 6-30), behavioural intentions (range: 6-42), and dissemination of training content. Implementation outcomes were evaluated using the Normalization MeAsure Development (NoMAD) tool, assessing the constructs of coherence (range: 4-20), cognitive participation (range: 4-20), collective action (range: 7-35) and reflexive monitoring (range: 5-25). RESULTS: Of the 29 allied health professionals who participated, 90% rated the program as 'excellent'/'very good', and 97% said the information was 'extremely'/'very' helpful for their everyday practice. We observed increases in confidence (mean difference [MD] = 6.3, standard deviation [SD] = 2.7, t25  = 11.87, P < .001) and intentions (MD = 3.6, SD = 8.1, t23  = 2.2, P = .04) related to health literacy practices after 6 weeks. Improved confidence was retained over 6 months (MD = 7.1, SD = 5.2, t18  = 5.96, P < .001). After 6 months, 95% of participants (n = 19) reported using teach-back and 50% (n = 10) reported having used a readability formula. Eight-five per cent of participants (17/20) had trained others in health literacy, reaching n = 201 allied health professionals and students. NoMAD scores were highest in relation to cognitive participation (/20) (M = 18.2, SD = 2.1) and lowest in relation to collective action (/35) (M = 25.4, SD = 3.0). CONCLUSIONS: A train-the-trainer model appears to be a feasible method to disseminate health literacy training, but additional work may be needed to improve the collective work done to enable health literacy practices in real-world clinical contexts. SO WHAT: Staff training is particularly important in highly diverse areas where patients are disproportionately affected by low health literacy.

Tracking Preschoolers' Lifestyle Behaviors and Testing Maternal Sociodemographics and BMI in Predicting Child Obesity Risk.

BACKGROUND: Longitudinal data investigating tracking of children's lifestyle behaviors and predictors of childhood obesity are limited. OBJECTIVES: We examined changes in children's lifestyle behaviors (dietary, physical activity, and screen time) from ages 2-5 y to determine if maternal sociodemographic factors and BMI predict child obesity at 3.5 y and 5 y. METHODS: Data were obtained from 667 first-time mothers who were recruited into the Healthy Beginnings Trial at 24-34 weeks of gestation in Sydney, Australia. Child lifestyle behaviors were assessed using face-to-face questionnaire interviews with mothers. To measure child and maternal anthropometry, BMI (in kg/m2) was calculated using measured height and weight. Children were categorized as overweight or obese based on the International Obesity Task Force criteria. We used 1-factor repeated-measures ANOVA to track preschoolers' lifestyle behaviors and multiple logistic regression to determine obesity predictors. RESULTS: In children aged 2-5 y, consumption of vegetables (ηp2 = 0.06; P < 0.005) and milk (ηp2 = 0.02; P < 0.001) decreased, whereas physical activity (ηp2 = 0.07; P < 0.001) increased. Discretionary foods (sweet snacks, fast foods, salty snacks, processed meats, confectionary) (ηp2 = 0.03-0.25; P ≤ 0.01) and screen time (ηp2 = 0.39; P < 0.001) increased. Maternal BMI (in kg/m2) (Exp ß: 1.06; 95% CI:1.01, 1.12 ; P=0.02), marital status (married/de facto compared with single) (Exp ß: 0.06; 95% CI:0.01, 0.26; P < 0.001), and child BMI at 2 y (Exp ß: 1.82; 95% CI: 1.46, 2.27; P < 0.001) predicted overweight/obesity at 3.5 y. Child BMI at 3.5 y (Exp ß: 3.51; 95% CI: 2.50, 4.93; P < 0.001) predicted obesity at 5 y. CONCLUSIONS: Poor dietary and lifestyle behaviours track in early childhood, with maternal single-parent status and high maternal and child BMI at 2 y predicting earlier obesity onset.

Development of an Electronic Questionnaire to Assess Sports Nutrition Knowledge in Athletes.

Background: Sports nutrition knowledge (SNK) is essential for athletes to support selection of a diet to optimize sports performance. Unfortunately, assessment of SNK is limited by a lack of well-validated instruments. Valid assessment of SNK would assist in identifying gaps in athlete knowledge, as well as tailoring and evaluating nutrition education interventions.Objectives: The aim of this study was to develop and conduct content validation on a SNK questionnaire for athletes.Methods: Focus groups (FG) with experienced sports nutritionists at four elite sporting institutions in Australia and New Zealand were conducted to inform instrument development. FGs were recorded, transcribed verbatim and broad themes identified. Draft items for the Platform to Evaluate Athlete Knowledge of Sports Nutrition Questionnaire (PEAKS-NQ) were developed using FG themes, the scientific literature, and a sports nutrition position stand. FG participants were subsequently invited to review the PEAKS-NQ using a modified Delphi process to refine draft items and inform content validity.Results: Participants (n = 16; median experience 11.5 years) identified key assessment domains including general nutrition knowledge along with SNK and supported development of an electronic instrument with food images. The electronic PEAKS-NQ was subsequently developed and reviewed by a subset of FG participants (n = 11/16). This informed changes to 41/94 items with none removed. The final PEAKS-NQ assessed knowledge of food groups, macro- and micronutrients, competition nutrition, dietary supplements and skills in adjusting dietary intake to different situations.Conclusion: Minor adaptation to incorporate local foods would facilitate international use of the PEAKS-NQ. Further validation, including athlete performance on the instrument, is warranted.

Wholegrain and legume consumption and the 5-year incidence of age-related cataract in the Blue Mountains Eye Study.

The present study aims to investigate the effect of wholegrain and legume consumption on the incidence of age-related cataract in an older Australian population-based cohort. The Blue Mountains Eye Study (BMES) is a population-based cohort study of eye diseases among older adults aged 49 years or older (1992-1994, n 3654). Of 2334 participants of the second examination of the BMES (BMES 2, 1997-2000), 1541 (78·3 % of survivors) were examined 5 years later (BMES 3) who had wholegrain and legume consumption estimated from the FFQ at BMES 2. Cataract was assessed using photographs taken during examinations following the Wisconsin cataract grading system. Multivariable-adjusted logistic regression models were used to assess associations with the 5-year incidence of cataract from BMES 2 (baseline) to BMES 3. The 5-year incidence of cortical, nuclear and posterior subcapsular (PSC) cataract was 18·2, 16·5 and 5·9 %, respectively. After adjustment for age, sex and other factors, total wholegrain consumption at baseline was not associated with incidence of any type of cataract. High consumption of legumes showed a protective association for incident PSC cataract (5th quintile: adjusted OR 0·37; 95 % CI 0·15, 0·92). There was no significant trend of this association across quintiles (P = 0·08). In this older Australian population, we found no associations between wholegrain intake at baseline and the 5-year incidence of three cataract types. However, intake of legumes in the highest quintile, compared with the lowest quintile, may protect against PSC formation, a finding needing replication in other studies.

Nutritional parameters associated with hospital admissions in patients being treated for head and neck cancer.

PURPOSE: This study analysed nutritional parameters (baseline body mass index (BMI), weight changes and enteral nutrition (EN) use, and their association with hospital admissions during radiotherapy in patients with head and neck cancer (HNC)). METHODS: A retrospective review of patients diagnosed with HNC and treated with radiotherapy between October 2012 and April 2014 was conducted. Data on each subject's diagnosis, age, sex, chemotherapy, previous surgery, EN use, weight changes, and BMI were examined for their association with hospital admissions during treatment. RESULTS: Eighty-three patients were included, mean age (±standard deviation) = 61 (± 11 years). Thirty-four percent had self-reported weight loss at diagnosis, and mean BMI was 26.2 ± 5.3 kg/m2. Mean weight change during treatment was - 5.1 ± 6.2%. Ten patients used EN, with mean weight stabilisation during EN use (0.3 ± 5.1%). Higher presenting BMI, younger age, and definitive radiotherapy ± chemotherapy predicted greater weight loss (p < 0.05). Critical weight loss ≥ 5% was associated with a higher number of hospital admissions for nutrition reasons (n = 10) (p = 0.011) compared with those without critical weight loss (n = 2). EN use was associated with a higher number of nutrition-related admissions; however, it did not predict length of stay among those admitted. CONCLUSION: Critical weight loss during radiotherapy was associated with unplanned nutrition-related hospital admissions. Higher BMI was associated with greater weight loss during radiotherapy, whilst EN use assisted in weight preservation. Further research around patient selection for nutritional interventions aimed at preventing critical weight loss and unplanned hospital admissions is needed.

Effectiveness of a Web-Based Menu-Planning Intervention to Improve Childcare Service Compliance With Dietary Guidelines: Randomized Controlled Trial.

BACKGROUND: Foods provided in childcare services are not consistent with dietary guideline recommendations. Web-based systems offer unique opportunities to support the implementation of such guidelines. OBJECTIVE: This study aimed to assess the effectiveness of a Web-based menu planning intervention in increasing the mean number of food groups on childcare service menus that comply with dietary guidelines. Secondary aims were to assess the impact of the intervention on the proportion of service menus compliant with recommendations for (1) all food groups; (2) individual food groups; and (3) mean servings of individual food groups. Childcare service use and acceptability of the Web-based program were also assessed. METHODS: A single-blind, parallel-group randomized controlled trial was undertaken with 54 childcare services in New South Wales, Australia. Services were randomized to a 12-month intervention or usual care control. Intervention services received access to a Web-based menu planning program linked to their usual childcare management software system. Childcare service compliance with dietary guidelines and servings of food groups were assessed at baseline, 3-month follow-up, and 12-month follow-up. RESULTS: No significant differences in the mean number of food groups compliant with dietary guidelines and the proportion of service menus compliant with recommendations for all food groups, or for individual food groups, were found at 3- or 12-month follow-up between the intervention and control groups. Intervention service menus provided significantly more servings of fruit (P<.001), vegetables (P=.03), dairy (P=.03), and meat (P=.003), and reduced their servings of discretionary foods (P=.02) compared with control group at 3 months. This difference was maintained for fruit (P=.03) and discretionary foods (P=.003) at 12 months. Intervention childcare service staff logged into the Web-based program an average of 40.4 (SD 31.8) times and rated the program as highly acceptable. CONCLUSIONS: Although improvements in childcare service overall menu and individual food group compliance with dietary guidelines were not statistically significant, findings indicate that a Web-based menu planning intervention can improve the servings for some healthy food groups and reduce the provision of discretionary foods. Future research exploring the effectiveness of differing strategies in improving the implementation of dietary guidelines in childcare services is warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ANZCTR): 16000974404; http://www.anzctr.org.au/ACTRN12616000974404.aspx.

The Combination of Healthy Diet and Healthy Body Weight Is Associated with Lower Risk of Nuclear Cataract in the Blue Mountains Eye Study.

BACKGROUND: Greater adherence to dietary guidelines has previously been found to be associated with decreased risk of visual impairment. However, whether or not this association extends to age-related cataract, 1 of the leading causes of visual impairment, is unknown. OBJECTIVES: The aim of this study was to assess the association between adherence to dietary guidelines, using total diet score, and incidence of age-related cataract. METHODS: Of 3654 baseline participants of the population-based Blue Mountains Eye Study cohort (1992-1994), 2334 (75.8% survivors) and 1952 (76.7% survivors) were examined after 5 and 10 y, respectively. Cataract was assessed from lens photographs using the Wisconsin Cataract Grading System. Baseline total diet score was calculated from FFQ data following a modified version of the Healthy Eating Index for Australians. OR with 95% CI were estimated using discrete logistic regression analyses, adjusting for age, sex, and other confounders. To test interaction, a cross-product term of 2 factors was included in regression models. RESULTS: Of 2173 participants (84.7% of those returned for 1 or both follow-ups) with total diet score estimated, 57% were women, mean baseline age was 63.9 ± 8.4y, and mean baseline BMI was 26.3 ± 4.3 kg/m2. After multivariable adjustment, baseline total diet score was not associated with incidence of any cataract. A multiplicative interaction was observed between total diet score and BMI for incident nuclear cataract (P-interaction = 0.04): increasing baseline total diet score was associated with decreased risk of nuclear cataract among participants with BMI <25 (per unit increased total diet score, OR: 0.90; 95% CI: 0.81, 0.99; P = 0.02), but not among participants with BMI ≥25 (OR: 1.00; 95% CI: 0.92, 1.10; P = 0.95). CONCLUSIONS: Adherence to dietary guidelines had no appreciable influence on cataract development overall in this older Australian population. However, adherence to dietary guidelines combined with healthy BMI is associated with decreased risk of nuclear cataract, an aging marker.

Carbohydrate nutrition variables and risk of disability in instrumental activities of daily living.

PURPOSE: We aimed to examine the prospective association between dietary glycemic index (GI) and glycemic load (GL) of foods consumed, intakes of carbohydrates and fiber, and the ability to perform activities of daily living (ADL) in older adults. METHODS: A total of 844 participants from the Blue Mountains Eye Study aged 60 years or older were examined from 2002-2004 to 2007-2009. Dietary information was collected using a validated, semi-quantitative food-frequency questionnaire. The Older Americans Resources and Services activities of daily living scale were administered to assess the functional status of participants. Multivariable logistic regression analysis was performed. RESULTS: After multivariable adjustment, participants who were in the second and third quartiles of energy-adjusted total fiber intake compared to those in the first quartile of intake (reference group) at baseline had reduced risk of incident impaired instrumental activities of daily living (IADL) 5 years later: OR, 0.39 (95% CI 0.22-0.70) and OR 0.54 (95% CI 0.30-0.95), respectively. Analyses that involved dichotomized total fiber intake showed that participants in the upper three quartiles of total fiber intake (> 19 g/day), compared to those in the lowest quartile of intake (≤ 19 g/day) or reference group, had reduced IADL disability risk 5 years later: OR 0.49 (95% CI 0.31-0.79). Non-significant associations were observed with total carbohydrates, GI, and GL and with risk of impaired total and basic ADL at 5-year follow-up. CONCLUSIONS: Habitual fiber consumption might be beneficial in leading to improved health status subserving performance of instrumental daily activities, needed to function in the community.

Relationship of dietary nitrate intake from vegetables with cardiovascular disease mortality: a prospective study in a cohort of older Australians.

PURPOSE: Short-term trials indicate inorganic nitrate and nitrate-rich vegetables may have vascular health benefits. However, few observational studies have explored the relationship between nitrate intake and long-term cardiovascular disease (CVD) outcomes. The primary aim of this study was to investigate the association of nitrate intake from vegetables with CVD mortality in a sample of older Australians. METHODS: A subgroup of participants without diabetes or major CVD at baseline (1992-1994) were included from the Blue Mountains Eye Study, a population-based cohort study of men and women aged ≥ 49 years. Diets were evaluated using a validated food frequency questionnaire at baseline, 5 years and 10 years of follow-up. Vegetable nitrate intake was estimated using a comprehensive vegetable nitrate database. Cox proportional hazard regression was used to explore the association between vegetable nitrate intake and CVD mortality. RESULTS: During 14 years of follow-up, 188/2229 (8.4%) participants died from CVD. In multivariable-adjusted analysis, participants in quartile 2 [69.5-99.6 mg/day; HR 0.53 (95% CI 0.35, 0.82)], quartile 3 [99.7-137.8 mg/day; HR 0.51 (95% CI 0.32, 0.80)], and quartile 4 [> 137.8 mg/day; HR 0.63 (95% CI 0.41, 0.95)] of vegetable nitrate intake had lower hazards for CVD mortality compared to participants in quartile 1 (< 69.5 mg/day). CONCLUSIONS: In older Australian men and women, vegetable nitrate intake was inversely associated with CVD mortality, independent of lifestyle and cardiovascular risk factors. These findings confirm a recent report that intake of vegetable nitrate lowers the risk of CVD mortality in older women and extend these findings to older men.

Development of an Athlete Diet Index for Rapid Dietary Assessment of Athletes.

Food-based diet indices provide a practical, rapid, and inexpensive way of evaluating dietary intake. Rather than nutrients, diet indices assess the intake of whole foods and dietary patterns, and compare these with nutrition guidelines. An athlete-specific diet index would offer an efficient and practical way to assess the quality of athletes' diets, guide nutrition interventions, and focus sport nutrition support. This study describes the development and validation of an Athlete Diet Index (ADI). Item development was informed by a review of existing diet indices, relevant literature, and in-depth focus groups with 20 sports nutritionists (median of 11 years' professional experience) from four elite athlete sporting institutes. Focus group data were analyzed (NVivo 11 Pro; QSR International Pty. Ltd., 2017, Melbourne, Australia), and key themes were identified to guide the development of athlete-relevant items. A modified Delphi survey in a subgroup of sports nutritionists (n = 9) supported item content validation. Pilot testing with athletes (n = 15) subsequently informed face validity. The final ADI (n = 68 items) was categorized into three sections. Section A (n = 45 items) evaluated usual intake, special diets or intolerances, dietary habits, and culinary skills. Section B (n = 15 items) assessed training load, nutrition supporting training, and sports supplement use. Section C (n = 8 items) captured the demographic details, sporting type, and caliber. All of the athletes reported the ADI as easy (40%) or very easy (60% of participants) to use and rated the tool as relevant (37%) or very relevant (63% of participants) to athletes. Further evaluation of the ADI, including the development of a scoring matrix and validation compared with established dietary methodology, is warranted.