Evaluation of an Environmental Nutrition Intervention at the 2018 Commonwealth Games.

There has been an increasing expectation that the food provided for athletes at major competition events meets the specific dietary and performance needs of athletes. The aim of this study was to map the range of food service nutrition schemes that were implemented prior to and during a major competition event (2018 Commonwealth Games) and evaluate these schemes through staff training satisfaction, athlete feedback, and quality assurance checks. This study followed a case study design with nutrition schemes as follows: informing (nutrition labelling), enabling (staff training, nutrition service), and engineering (modification to menus and recipes). Overall, participants reported that they easily found items on the menu that met their nutritional/dietary needs. When asked how useful the schemes were in helping them to identify items that meet their needs, the majority of participants found the nutrition cards (n = 227, 71%) and serving staff (n = 212, 66%) 'useful/very useful'. 'Good/very good' ratings were received by >90% of respondents for speed of service, staff politeness, and knowledge of the menu. Participants (n = 316) who rated the nutrition staff as 'useful/very useful' gave a higher median rating for the menu. Past events have focused on the impact of a single component in the food environment; however, taking a whole systems approach resulted in more suitable food provision to meet the dietary needs of athletes.

Validation of a Turkish Version of the Athlete Food Choice Questionnaire.

There are multiple influences on food choice for athletes. The aim of this study was to assess the validity and reliability of a Turkish Athlete Food Choice Questionnaire (Turkish-AFCQ) and describe the main factors influencing food choices. A multi-step process of language and content validation, Explanatory Factor Analysis, Confirmatory Factor Analysis, and test-retest reliability were used to examine factorial structure and construct validity (convergent and discriminant) and reliability (internal and external). The translated Turkish-AFCQ was administered to 446 athletes (59% male, median age = 21 years) from a variety of sports. The original nine-factor structure was validated, external reliability was acceptable, and all factors achieved acceptable discriminate validity. Convergent validity and internal reliability received tenable-ideal ratings for seven and eight factors, respectively. Interpretation and future application are discussed for low-performing factors 'food and health awareness' and 'influence of others'. The factor most frequently (never 1-always 5) influencing choices was 'performance' (Md = 4.33) and the least was both the 'influence of others' and 'food values and beliefs' (Md = 2.67). The Turkish-AFCQ can be used to expand researchers' and practitioners' understanding of the relative influence multiple factors have on food choices, and this study provides a model for AFCQ linguistic translation and validation.

Carbohydrate knowledge, beliefs, and intended practices, of endurance athletes who report exercise-associated gastrointestinal symptoms.

This study aimed to explore carbohydrate (CHO) knowledge, beliefs, and intended practices of endurance athletes who experience exercise-associated gastrointestinal symptoms (Ex-GIS) compared to those without Ex-GIS. A validated online questionnaire was completed by endurance athletes (n = 201) participating in >60 min of exercise that present with Ex-GIS (n = 137) or without (n = 64). Descriptive statistics were used for parametric and non-parametric data with appropriate significance tests. Associations between categorical data were assessed by Chi-square analysis, and post-hoc Bonferroni tests were applied when significant. A content analysis of open-ended responses was grouped into themes, and quantitative statistics were applied. Participants included runners (n = 114, 57%), triathletes (n = 43, 21%) and non-running sports (n = 44, 21%) who participate in recreational competitive (n = 74, 37%), recreational non-competitive (n = 64, 32%), or competitive regional, national, or international levels (n = 63, 31%). Athletes correctly categorized CHO (x̄ = 92-95%) and non-CHO (x̄ = 88-90%) food and drink sources. On a Likert scale of 1 (strongly disagree) to 5 (strongly agree) athletes typically agree or strongly agree that consuming CHO around key training sessions and competitions enhances athletic performance [median = 4 (IQR, 4-5)], and they intend to consume more CHO around exercise [median = 3 (IQR, 2-3)]. No differences in beliefs and intentions were found among athletes with or without Ex-GIS. To enhance athletic performance, most endurance athletes intend to consume more CHO around exercise. Adequate knowledge of CHO-containing food sources was apparent; however, specific CHO ingestion practices remain to be verified.

Food Provision at the Olympic Games in the New Millennium: A Meta-narrative Review.

BACKGROUND AND OBJECTIVE: The objective of this meta-narrative review was to identify, organise and map the literature on food provision and nutrition support at the summer and winter Olympic and Paralympic Games (OPG)  and similar major competition events over the past 21 years. This builds on a comprehensive update of a previous historical review of the evolution of food provision at the summer Olympic Games up until 2000 and considers contemporary issues such as the global pandemic and sustainability goals. METHODS: A range of sources included primary research and review articles, edited book chapters, theses, conference papers or abstracts, International Olympic Committee reports, Organising Committees' food vision and post-Games reports, independent professional reports, and media and periodicals including magazines and trade journals. The search strategy included four steps: a database search that complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews criteria, a search of the Olympic Studies Centre, a review of reference lists for unpublished sources, and a Google search for additional media reports. The researchers followed an iterative process where emerging narratives were discussed, recorded and refined as data were extracted. RESULTS: The data from 229 records were extracted into a spreadsheet and grouped according to the type of evidence and specific event, then presented chronologically to give a perspective on the development of food provision and nutrition support. Eleven narratives emerged from the data extraction: 'description of meals, menus and food', 'vision of the food provision', 'food safety', 'catering company involvement', 'sponsorship or contracts with food companies', 'athlete perspective', 'stakeholder perspective', 'athlete food intake,' 'nutrition input in food provision', 'food environment' and 'sustainability'. CONCLUSION: Results suggest that athletes' dining expectations, organising committee budgets, expert input and current global trends have led to food delivery changes. The OPG food environment has the capacity to positively influence the dietary choices of athletes and teams, while evolving to meet contemporary global challenges such as COVID-19 and sustainability targets.

The implementation of interprofessional education: a scoping review.

INTRODUCTION: Implementation of interprofessional education (IPE) is recognised as challenging, and well-designed programs can have differing levels of success depending on implementation quality. The aim of this review was to summarise the evidence for implementation of IPE, and identify challenges and key lessons to guide faculty in IPE implementation. METHODS: Five stage scoping review of methodological characteristics, implementation components, challenges and key lessons in primary studies in IPE. Thematic analysis using a framework of micro (teaching), meso (institutional), and macro (systemic) level education factors was used to synthesise challenges and key lessons. RESULTS: Twenty-seven primary studies were included in this review. Studies were predominantly descriptive in design and implementation components inconsistently reported. IPE was mostly integrated into curricula, optional, involved group learning, and used combinations of interactive and didactic approaches. Micro level implementation factors (socialisation issues, learning context, and faculty development), meso level implementation factors (leadership and resources, administrative processes), and macro level implementation factors (education system, government policies, social and cultural values) were extrapolated. Sustainability was identified as an additional factor in IPE implementation. CONCLUSION: Lack of complete detailed reporting limits evidence of IPE implementation, however, this review highlighted challenges and yielded key lessons to guide faculty in the implementation of IPE.

An exploratory study of the management strategies reported by endurance athletes with exercise-associated gastrointestinal symptoms.

This exploratory study investigated endurance athletes self-reported exercise-associated gastrointestinal symptoms (Ex-GIS) and associated strategies to manage symptomology. Adult endurance athletes with a history of Ex-GIS (n = 137) participating in events ≥ 60 min completed an online validated questionnaire. Respondents included runners (55%, n = 75), triathletes (22%, n = 30), and non-running sports (23%, n = 32), participating at a recreationally competitive (37%, n = 51), recreationally non-competitive (32%, n = 44), and competitive regional/national/international (31%, n = 42) levels. Athletes identified when Ex-GIS developed most frequently either around training (AT), around competitions (AC), or equally around both training (ET) and competitions (EC). Athletes reported the severity of each symptom before, during, and after exercise. Athletes predominantly categorized Ex-GIS severity as mild (< 5/10) on a 0 (no symptoms) to 10 (extremely severe symptoms) visual analog symptomology scale. The Friedman test and post hoc analysis with Wilcoxon signed rank test was conducted with a Bonferroni correction applied to determine differences between repeated measures. The only severe symptom of significance was the urge to defecate during training in the ET group (Z = -0.536, p = 0.01). Ex-GIS incidence was significantly higher during training and competitions in all categories. A content review of self-reported strategies (n = 277) to reduce Ex-GIS indicated popular dietary strategies were dietary fiber reduction (15.2%, n = 42), dairy avoidance (5.8%, n = 16), and a low fermentable oligosaccharides, monosaccharides, and polyols (FODMAP) diet (5.4%, n = 15). In contrast, non-dietary strategies included the use of medications (4.7%, n = 13) and relaxation/meditation (4.0%, n = 11). On a Likert scale of 1-5, the most successful dietary strategies implemented were dietary fiber reduction (median = 4, IQR = 4, 5), low FODMAP diets (median = 4, IQR = 4, 5), dairy-free diets (median = 4, IQR = 4, 5), and increasing carbohydrates (median = 4, IQR = 3, 4). Accredited practicing dietitians were rated as the most important sources of information for Ex-GIS management (n = 29). Endurance athletes use a variety of strategies to manage their Ex-GIS, with dietary manipulation being the most common.

Reliability of the Athlete Food Choice Questionnaire in Diverse Settings.

Understanding the factors that influence an athletes' food choice is important to supporting optimal dietary intake. The Athlete Food Choice Questionnaire (AFCQ) is a new validated tool for assisting practitioners and researchers to understand athlete eating behaviours. However, the AFCQ previously has only been applied at international competition events. This observational study explored the online application of the AFCQ outside of the competition environment with detailed examination of factor reliability. The AFCQ factors include 'nutritional attributes of the food', 'emotional influences', 'food and health awareness', 'influence of others', 'usual eating practices', 'weight control', 'food values and beliefs', 'sensory appeal', and 'performance'. A total of 131 athletes, representing 19 countries and 36 sports, participated using an online questionnaire. Reliability via Cronbach's alpha (α) and item correlation scores were compared to those from previous competition events. Acceptable reliability was attained for seven of the nine factors (α ≥ 0.7, range 0.70-0.92). 'Food values and beliefs' and 'usual eating practices' (α = 0.60, 0.64) were tolerable and consistent against previous major competition samples, indicating that the setting is unlikely responsible for lower reliability scores. Three factors ('emotional influence'; 'nutritional attributes of the food'; 'influence of others') differed in reliability between the online sample compared to one or both major competition samples. The 'religious food beliefs' item within the 'food values and beliefs' factor may warrant removal due to recurrent low internal consistency. This study confirms the AFCQ's reliability regardless of competition phase and supports use of the AFCQ for understanding the eating behaviours of athletes.

Determinants of Food Choice in Athletes: A Systematic Scoping Review.

BACKGROUND: The individual determinants of food choice have been extensively investigated in the general population, but there have been limited studies in athletes. A better understanding of the food making decisions can help to target interventions that lead to optimal intake for athletes' health and performance. A scoping review will provide an understanding of the sports and settings that have been investigated, the methods and approaches to assessing food choice, as well as the factors influencing food choice. OBJECTIVE: The objective of this review was to map the available evidence on the multi-faceted determinants of food choice in athletes and describe key influences impacting their choices. ELIGIBILITY CRITERIA: Athletes 16 years and over from any country who engage in physical activity with the intent to be competitive. Studies were included if they reported the multi-faceted determinants of food choice as either a primary or secondary outcome. All study designs were considered. SOURCES OF EVIDENCE: This review followed the PRISMA extension for Scoping Reviews. Eleven databases including PubMed, Web of Science (Clarivate Analytics), SPORTDiscus (EBSCO), PsycNET (APA), Health Collection (Informit), CINAHL (EBSCO), the Cochrane Library, ProQuest Dissertations and Theses Global, Trove (National Library of Australia), JBI (Ovid), and Google scholar were searched between September-November 2020 and updated in March 2021. Charting of Data Search results were screened with selected studies extracted into a summary table established a priori by the authors. Study quality was assessed using standardised reporting tools for qualitative and quantitative research designs. The scope and quality of evidence was summarised and reported. RESULTS: A total of 15 studies were included. Qualitative research included one research thesis and six primary research studies using both focus groups and semi-structured interviews. Quantitative research included one research thesis and seven primary research studies with cross-sectional design using different validated and non-validated survey instruments. No longitudinal or intervention studies were found. The majority of studies have been published since 2018 and conducted across multiple countries with either mixed cohorts of athletes or focused on predominately endurance or team sports. The quality of reporting was variable, particularly for qualitative research. Outcomes suggested that performance and health were relevant to athlete food choice, with varying impact of competition season, the level of experience, the culture of the sport, the cultural background or nationality of the athlete, athlete sex and the food environment. CONCLUSION: More research is needed on the multi-faceted determinants of food choice in different cohorts of athletes, particularly females. Future research could explore the relationship between food choice, nutrition knowledge and diet quality or the change in food choice across the phase of the seasons and through injury and illness. Use of validated measurement tools and robust reporting will enable critical interpretation of the study methods and outcomes for use in practice. Registration OSF Registries: Open-ended registration 25th Sept 2020 https://doi.org/10.17605/OSF.IO/4PX2A.

A qualitative exploration of the future of nutrition and dietetics in Australia and New Zealand: Implications for the workforce.

AIM: We aimed to explore the future roles of nutrition and dietetics professionals, and what capabilities the workforce would need to fulfil these roles. METHOD: A qualitative interpretive approach was employed. We conducted individual interviews with nutrition and non-nutrition thought leaders external to the profession. In addition, we conducted focus groups with experts within the nutrition and dietetics profession, academic dietetics educators and students/recent nutrition and dietetics graduates (total sample n = 68). Key nutrition-related issues and challenges, drivers for change and potential future roles of the profession were explored. Data were analysed using a team-based thematic analysis approach. RESULTS: Future roles of nutrition and dietetics professionals were described as food aficionados, diet optimisers, knowledge translators, equity champions, systems navigators and food systems activists, change makers, activists and disruptors. In addition, science was identified as a uniting framework underpinning the professions. An additional 16 critical capabilities were considered to underpin practice. CONCLUSION: The results demonstrated that the current and future needs for workforce education and development need to address the impact of climate change, growing inequities, the democratisation of knowledge and the disruption of health and food systems. Education providers, regulators, professional associations and citizens need to work together to realise roles that will deliver on better health for all.

The Athlete Food Choice Questionnaire (AFCQ): Validity and Reliability in a Sample of International High-Performance Athletes.

PURPOSE: The Athlete Food Choice Questionnaire (AFCQ) is a novel tool for understanding factors influencing athlete food selection and providing context to nutrition knowledge and diet quality data. Reliability, face, and content validity have been previously established during development. The aim of this study is to evaluate the AFCQ's factorial structure, reliability, and construct validity in an independent sample of international high-performance athletes. METHODS: The AFCQ contains 36 items within nine factors. Participants rate how frequently (1 never to 5 always) items influence their choices. Model consistency and construct validity was evaluated by confirmatory factor analysis. Measures included model fit incidences and duplicate methods examining reliability, convergent, and discriminant validity. RESULTS: Athletes (n = 232) at the 2018 Commonwealth Games, Gold Coast, Australia, completed the AFCQ. A modified 32-item model achieved discriminant validity for all factors and convergent validity for "emotional influence," "food and health awareness," "nutritional attributes of food," "performance," and "influence of others." Reliability measures of all constructs except "usual eating practice" and "food values and beliefs" were above acceptable thresholds, although "usual eating practice" was considered tolerable and conditionally accepted. CONCLUSION: The AFCQ was confirmed in its original nine-factor structure in an independent sample of high-performance athletes. This provides a detailed and transparent account of the construct validity of the AFCQ, adding to the foundation of evidence for this new instrument. The AFCQ captures the unique influences specific to athletes while being broad enough for application across diverse sporting and culturally mixed cohorts. This tool could assist sports science professionals in making more informed and effective decisions around strategies to support athletes, including the ability to triage for specific sports nutrition advice.

Development and validation of a questionnaire investigating endurance athletes practices to manage gastrointestinal symptoms around exercise.

AIM: To develop and validate a questionnaire investigating endurance athletes' carbohydrate beliefs, knowledge, information sources, and other dietary and non-dietary practices related to exercise-associated gastrointestinal symptoms. METHODS: A questionnaire was developed by a review of relevant literature and sports-related questionnaires, and input from five experienced sports dietitians. Item construct and format was adapted and modified from a previous questionnaire. The modified questionnaire sought information on demographics, nutrition knowledge, beliefs, intended practices, information sources and exercise-associated gastrointestinal symptoms. A five-phase validity process was conducted to determine content, face and construct validity, item difficulty and internal reliability of the questionnaire. The Delphi technique was applied with experts over three anonymous rounds. Items were reviewed to determine whether to keep, modify, or delete, rate the relevance of each item using a content validity index (CVI), and provide comments. A content analysis was conducted on all comments after each round. Online interviews were conducted with a pilot group of endurance athletes (n = 15) to assess item difficulty and feasibility. Nutrition knowledge was compared between pilot group of athletes and experts to determine construct validity and internal consistency. A test-retest process was applied to a second pilot group (n = 8) to verify questionnaire reliability. RESULTS: High CVI (≥.83) and agreement scores were obtained through the Delphi technique. High reliability (r = .942) and acceptable internal consistency (α = .53-.78) of the questionnaire were obtained. CONCLUSIONS: The questionnaire was shown to be a valid and reliable tool that will be of use for clinicians and research purposes.

Key concepts for dietetic curriculum: An observational study of Australian dietitians' perceptions.

AIM: A concept-based approach to dietetic curriculum design has been proposed to prevent content overload and promote critical thinking. Fifty-six concepts were identified in a previous study. The aim of the present study was to investigate whether the dietetic profession views these concepts as representative of current practice and key for nutrition and dietetics education, and identify any new or emerging concepts. METHODS: Accredited Practising Dietitians (APDs) were invited to participate in a self-administered online survey that included scale responses on the relevance of the 56 concepts and open-ended suggestions of additional concepts. Respondent characteristics were also collected. RESULTS: Ninety-eight APDs completed the survey. Greater than 65% of respondents agreed/strongly agreed that all 56 concepts were relevant. There was less agreement on the concepts of acid-base balance; leadership; management; physical activity, exercise and health; quality assurance and improvement; risk; safety; stakeholder; standards; sustainability; systems and technology and health informatics. Respondents working in regional, rural and remote areas were less likely to agree that leadership was a key concept (χ2 = 4.45, P = .035). Respondents working in teaching and education were more likely to agree that sustainability was a key concept (χ2 = 7.02, P = .008). No new concepts were identified. CONCLUSIONS: The existing 56 concepts were considered key for nutrition and dietetics education. Although the respondents to this survey view these concepts as relevant to current practice, this may not represent the entire profession. It is yet to be determined if the concepts will meet future priorities for the dietetic workforce.

Outcomes of a nutrition service provided by dietitians at a major multi-cultural competition event: An observational study.

AIM: The nutrition service available for athletes competing at major events varies significantly and is dependent on advocacy for dietetic inclusion. The aim of this study was to describe the outcomes of a nutrition service designed and led by dietitians at a major international competition: the 2017 Taipei Universiade. METHODS: Athletes (university students aged 17-25 years) and officials that used the service were invited to participate. Occasions of service were recorded using standard pro formas and dietary analysis of consultations was conducted using Foodworks. RESULTS: The scope of the service included 242 enquiries, 884 weight checks, 25 skinfold measures and 37 consultations. A significantly higher proportion of females asked about food allergy/intolerance (26.2% vs 12.5%, P = .039) than males. Most athletes who sought a nutrition consultation had not received previous nutrition support (86.5%) and wanted performance-related meal plans and advice (81.1%). On average, their diets were adequate in micronutrients with the exception of calcium, and low in serves of vegetables and dairy products. The majority of athletes (72.9%) seeking a consultation reported that they did not follow a specific diet for their sport. Sports supplements, performance enhancers and vitamin-mineral supplements use was 45.9% (n = 17), 13.5% (n = 5) and 13.5% (n = 5), respectively. Most athletes were of a high international calibre, however, reported low confidence in their nutrition knowledge and did not consistently apply knowledge to practice. CONCLUSION: This demonstrates a need for nutrition services by dietitians at this and similar events to improve the dietary intake of young adult athletes.

Inclusion of Nutrition Expertise in Catering Operations at a Major Global Sporting Event: A Qualitative Case Study Using a Foodservice Systems Approach.

BACKGROUND: Major sporting event catering is a significant undertaking for foodservice providers, particularly with an increasing focus on sustainability, global health, and nutrition demands of athletes. Yet, the inclusion of nutrition expertise in catering varies significantly between events. Foodservice systems models are commonly used to evaluate foodservice operations but to date have not been applied to catering and nutrition at major sporting events. OBJECTIVE: The aim of this exploratory case study was to gain in-depth insights of key stakeholders (catering management, chefs, organizers, and dietitians) regarding the integration of nutrition into the catering operation of a major global sporting event, with a focus on future continuity, and map this to the foodservice systems model using a program logic model. SETTING: Semistructured interviews were conducted with 12 stakeholders during and after the 2018 Commonwealth Games, Gold Coast, Australia. RESULTS: The 8 themes that emerged were related to planning and preparation, refining processes, improvement of the menu, better technology, increase in food allergies/intolerances, organization controls, experience of the workforce, and increased client knowledge of nutrition. The logic model demonstrated that the system is driven by policy and budget at the level of control prior to and during the planning phase but modified by the environment during operation. CONCLUSIONS: Despite recognition by stakeholders on the importance of change, there are barriers to the provision of suitable food. Integration of nutrition expertise into tender documents and budgets in major event catering will help ensure nutritionally adequate, culturally suitable, and safe menus for future events.

Key Factors Influencing the Food Choices of Athletes at two Distinct Major International Competitions.

This study aimed to identify the factors influencing the food choices of athletes at the Universiade and Commonwealth Games and explore differences in the cohort across sport, competition history and demographic characteristics. A sample of 385 athletes (n = 153, 2017 Universiade, Taiwan; n = 232, 2018 Commonwealth Games, Australia), from 69 countries and 29 sports participated in this cross-sectional observational study. Participants rated 36 items from the Athlete Food Choice Questionnaire and 11 additional items (gut comfort, doping risk, availability, location, money, convenience, time of day, hunger, medical conditions, and food allergies) on how frequently (1 never to 5 always) each influences their food choices. "Performance", "sensory appeal", "food and health awareness" and "weight control" were reported as most frequently, while the least were "emotional influence", "influence of others" and "food values and beliefs". Commonwealth Games athletes were older, more experienced and more likely to report "performance" (median = 4.33 versus 4.00, U = 20250.0, p = 0.012) and less likely to report "emotional influences" (median = 2.80 versus 3.20, U = 14273.0, p = 0.001) than Universiade athletes. Greater numbers of younger athletes were often or always influenced by available money. Athletes across all sports reported frequently considering gut comfort in their food choices. These results can inform nutrition education strategies of high-performance athletes.

The influence of current food and nutrition trends on dietitians' perceptions of the healthiness of packaged food.

OBJECTIVE: To investigate the influence of current food and nutrition trends on dietitians' perceptions of the healthiness of packaged foods. DESIGN: This observational study used a cross-sectional survey. Participants rated (strongly disagree to strongly agree) the extent to which a range of factors, independent of the energy, nutrient and ingredient content, influenced their perceptions of the healthiness of packaged foods. Two open-ended questions allowed for participants to list additional items they considered important. SETTING: Online survey. PARTICIPANTS: Australian dietitians (n 117). RESULTS: The greatest consensus was a positive influence of the fit within the core food groups and presence of seasonal ingredients, and a negative influence of an increasing number of additives. Mixed opinions were obtained for GM ingredients, locally sourced ingredients, labelling of animal welfare and organic certification. Nutritional indicators received a split where almost half of participants disagreed/strongly disagreed that they positively influenced their perception of healthiness. Content analysis of open-ended responses (n 53, 45 %) revealed four broad categories as important in considering healthiness: 'a whole food approach', 'marketing and labelling', 'product information' and 'context of diet'. A small number of responses (count of 6, 5 %) reported that packaging, advertising and features such as celebrity endorsement were a negative influence. CONCLUSIONS: Dietitians have a broad concept of the healthiness of packaged foods, which incorporates elements of food safety, wholeness of the ingredients and marketing. Providing unified messages to the consumer can help to build the public perception of dietitians as experts in nutrition advice and counselling.

Consumers' Perceptions of the Australian Health Star Rating Labelling Scheme.

The objective of this study was to explore consumers' use and perception of the Australian Health Star Rating (HSR). A purposive sample of fifteen Australian grocery shoppers was recruited into four focus groups using a supermarket intercept strategy. Focus group discussions were recorded, transcribed and analysed using an iterative approach to thematic analysis. Three key themes emerged from analysis. The HSR was seen as simple, uncluttered, easy to understand and useful for quick comparison across products. The nutrition information was viewed positively; however, there was little confidence in the HSR due to a perceived lack of transparency in the criteria used to determine the number of stars. Highly processed foods were generally seen as having inflated ratings and participants expressed concern that this would increase consumption of these products. Finally, there was a belief that the HSR had a lack of negative imagery limiting the dissuasive impact on consumers when presented with low-rated foods. Consumers saw benefits in the HSR but were sceptical about how the ratings were derived. Transparency about the development and education on the application may assist with consumers' perception of the HSR.

Using document analysis to identify core concepts for dietetics: The first step in promoting conceptual learning.

Concept-based approaches to curriculum design have been proposed in nursing and health sciences education to address the issue of content overload in curricula but have not been described in dietetics. This study aimed to identify core concepts for the dietetics discipline in Australia and investigate the commonality and differences in these concepts across different dietetic organizations across the world. This study used document analysis of a purposive sample of international dietetics competency or proficiency standards identified from English-speaking dietetic organizations worldwide. Content analysis was applied to the performance criteria or equivalent from 10 documents (nine organizations) to identify the most common elements. A total of 1,007 statements were analyzed. Fifty-six concepts were developed. The four most frequent concepts coded across all statements were "critical thinking," "communication," "nutrition and dietetic service," and "quality assurance and improvement." There were 55 concepts common to all standards. The concept of "food security" was not present in one of the standards from the United States. The concepts that emerged from this study were common across different English-speaking dietetic organizations across the world. Small differences on the emphasis of concepts, between different competency standards may reflect the health needs; health, political, economic, and social systems; and the cultural context of a country. Identifying core concepts in dietetics is the first step to help to inform curriculum design, which may address overcrowded curricular and promote conceptual learning.