Food pedagogy-key elements for urban health and sustainability: A scoping review.

Food-related issues are on the rise in urban areas around the world. Issues include unhealthy food habits and eating practices, disconnection from food and culture, social isolation and environmental unsustainability. There has been increasing consideration of pedagogical approaches, or food pedagogies, to address these challenges. This paper aims to identify the key elements and influences over food-related activities within food pedagogies that strive to improve urban health and sustainability. A scoping literature review was conducted using five electronic databases. Of the 271 abstracts identified, thirty-five articles met the inclusion criteria. The review identified four key elements: 'Everyday food experiences', 'Social relations', 'Culture', and 'Sustainable lifestyles' and two main influences: 'Professionals involved with food-related activities' and 'Spaces of learning/experiencing food-related activities'. The key elements and influences embrace pedagogical and practical attributes of food pedagogies that address the complex food-related issues. However, limited published research examines food pedagogies or attempts to develop an agreed, theoretically informed framework. This review provides understanding of important knowledge and practical implications of food pedagogies for multiple stakeholders involved in food-related activities, useful to the development of food education programs and food policies or initiatives for societal health and sustainability in urban areas.

Benchmarking the transparency, comprehensiveness and specificity of population nutrition commitments of major food companies in Malaysia.

BACKGROUND: The aim of this study was to assess the commitments of food companies in Malaysia to improving population nutrition using the Business Impact Assessment on population nutrition and obesity (BIA-Obesity) tool and process, and proposing recommendations for industry action in line with government priorities and international norms. METHODS: BIA-Obesity good practice indicators for food industry commitments across a range of domains (n = 6) were adapted to the Malaysian context. Euromonitor market share data was used to identify major food and non-alcoholic beverage manufacturers (n = 22), quick service restaurants (5), and retailers (6) for inclusion in the assessment. Evidence of commitments, including from national and international entities, were compiled from publicly available information for each company published between 2014 and 2017. Companies were invited to review their gathered evidence and provide further information wherever available. A qualified Expert Panel (≥5 members for each domain) assessed commitments and disclosures collected against the BIA-Obesity scoring criteria. Weighted scores across domains were added and the derived percentage was used to rank companies. A Review Panel, comprising of the Expert Panel and additional government officials (n = 13), then formulated recommendations. RESULTS: Of the 33 selected companies, 6 participating companies agreed to provide more information. The median overall BIA-Obesity score was 11% across food industry sectors with only 8/33 companies achieving a score of > 25%. Participating (p < 0.001) and global (p = 0.036) companies achieved significantly higher scores than non-participating, and national or regional companies, respectively. Corporate strategy related to population nutrition (median score of 28%) was the highest scoring domain, while product formulation, accessibility, and promotion domains scored the lowest (median scores < 10%). Recommendations included the establishment of clear targets for product formulation, and strong commitments to reduce the exposure of children to promotion of unhealthy foods. CONCLUSIONS: This is the first BIA-Obesity study to benchmark the population nutrition commitments of major food companies in Asia. Commitments of companies were generally vague and non-specific. In the absence of strong government regulation, an accountability framework, such as provided by the BIA-Obesity, is essential to monitor and benchmark company action to improve population nutrition.

Extent of implementation of food environment policies by the Malaysian Government: gaps and priority recommendations.

OBJECTIVE: To determine the degree of food environment policies that have been implemented and supported by the Malaysian Government, in comparison to international best practice, and to establish prioritised recommendations for the government based on the identified implementation gaps. DESIGN: The Healthy Food-Environment Policy Index (Food-EPI) comprises forty-seven indicators of government policy practice. Local evidence of each indicator was compiled from government institutions and verified by related government stakeholders. The extent of implementation of the policies was rated by experts against international best practices. Rating results were used to identify and propose policy actions which were subsequently prioritised by the experts based on 'importance' and 'achievability' criteria. The policy actions with relatively higher 'achievability' and 'importance' were set as priority recommendations for government action. SETTING: Malaysia. SUBJECTS: Twenty-six local experts. RESULTS: Majority (62 %) of indicators was rated 'low' implementation with no indicator rated as either 'high' or 'very little, if any' in terms of implementation. The top five recommendations were (i) restrict unhealthy food marketing in children's settings and (ii) on broadcast media; (iii) mandatory nutrition labelling for added sugars; (iv) designation of priority research areas related to obesity prevention and diet-related non-communicable diseases; and (v) introduce energy labelling on menu boards for fast-food outlets. CONCLUSIONS: This first policy study conducted in Malaysia identified a number of gaps in implementation of key policies to promote healthy food environments, compared with international best practices. Study findings could strengthen civil society advocacies for government accountability to create a healthier food environment.

A nutrient profiling assessment of packaged foods using two star-based front-of-pack labels.

OBJECTIVE: To compare two front-of-pack nutrition labelling systems for the assessment of packaged foods and drinks with Australian Dietary Guidelines. DESIGN: A cross-sectional nutrient profiling assessment. Food and drink products (n 20 225) were categorised into scoring levels using criteria for the Institute of Medicine (IOM) three-star system and the five-star Australian Health Star Rating (HSR). The effectiveness of these systems to categorise foods in accordance with Australian Dietary Guidelines was explored. SETTING: The study was conducted in Australia, using a comprehensive food database. SUBJECTS: Packaged food and drink products (n 20 225) available in Australia. RESULTS: Using the IOM three-star system, the majority (55 %) of products scored the minimum 0 points and 25·5 % scored the maximum 3 points. Using HSR criteria, the greatest proportion of products (15·2 %) scored three-and-a-half stars from a possible five and 12·5 % received the lowest rating of a half-star. Very few products (4·1 %) scored five stars. Products considered core foods and drinks in Australian Dietary Guidelines received higher scores than discretionary foods in all food categories for both labelling systems (all P<0·05; Mann-Whitney U test), with the exception of fish products using IOM three-star criteria (P=0·603). The largest discrepancies in median score between the two systems were for the food categories edible oils, convenience foods and dairy. CONCLUSIONS: Both the IOM three-star and Australian HSR front-of-pack labelling systems rated packaged foods and drinks broadly in line with Australian Dietary Guidelines by assigning core foods higher ratings and discretionary foods lower ratings.

Obesity framing for health policy development in Australia, France and Switzerland.

The obesity epidemic is a consequence of the interaction of cultural, environmental, genetic and behavioural factors; framing the issue is central to determining appropriate solutions. This study used content and thematic framing analysis to explore portrayal of responsibility for obesity in policy documents in Australia, France and Switzerland. For Australia and France, obesity causality was a combination of individual and environmental factors, but for Switzerland, it was predominantly individual. The primary solutions for all countries were health promotion strategies and children's education. Industry groups proposed more school education while health advocates advised government intervention. Where France emphasized cultural attitudes towards taste, Australia focused on sport. The French were most keen on legislating against unhealthy foods compared with Switzerland where there was opposition towards regulation of individual's choices. To curb the increasing prevalence of obesity, allocation of responsibility needs to be considered and initiatives enacted accordingly.

Health-related claims on food labels in Australia: understanding environmental health officers' roles and implications for policy.

OBJECTIVE: Health and related claims on food labels can support consumer education initiatives that encourage purchase of healthier foods. A new food Standard on Nutrition, Health and Related Claims became law in January 2013. Implementation will need careful monitoring and enforcement to ensure that claims are truthful and have meaning. The current study explored factors that may impact on environmental health officers' food labelling policy enforcement practices. DESIGN: The study used a mixed-methods approach, using two previously validated quantitative questionnaire instruments that provided measures of the level of control that the officers exercised over their work, as well as qualitative, semi-structured, in-depth interviews. SETTING: Local government; Australia. SUBJECTS: Thirty-seven officers in three Australian states participated in semi-structured in-depth interviews, as well as completing the quantitative questionnaires. Senior and junior officers, including field officers, participated in the study. RESULTS: The officers reported a high level of autonomy and control of their work, but also a heavy workload, dominated by concerns for public health and food safety, with limited time for monitoring food labels. Compliance of labels with proposed health claims regulations was not considered a priority. Lipsky's theory of street-level bureaucracy was used to enhance understanding of officers' work practices. CONCLUSIONS: Competing priorities affect environmental health officers' monitoring and enforcement of regulations. Understanding officers' work practices and their perceptions of enforcement is important to increase effectiveness of policy implementation and hence its capacity to augment education initiatives to optimize health benefits.

Parent and child interactions with two contrasting anti-obesity advertising campaigns: a qualitative analysis.

BACKGROUND: Social marketing has been proposed as a framework that may be effectively used to encourage behaviour change relating to obesity. Social advertising (or mass media campaigning) is the most commonly used social marketing strategy to address the issue of obesity. While social advertising has the potential to effectively communicate information about obesity, some argue that the current framing and delivery of these campaigns are ineffective, and may cause more harm than good. METHODS: We used a qualitative advertising reception study. 150 family groups (comprised of 159 parents and 184 children) were shown two Australian government anti-obesity advertisements: Measure Up (focused on problems associated with obesity) and Swap It (focused on solutions for obesity). Families were engaged in a discussion about the visual appeals, verbal messages and their perceptions about the impact of the advertisements on behavioural change. Open coding techniques and a constant comparative method of analysis was used to interpret the data. RESULTS: Many parents had strong personal resonance with the visual imagery within the campaigns. While Swap It had strong 'likeability' with children, many children believed that the messages about overweight and obesity were less personally relevant because they did not perceive themselves to be overweight. The content and delivery style of the verbal messages (the serious risk focused message in Measure Up compared to the upbeat, fun practical message in Swap It) influenced how different audiences (parents and children) interpreted the information that was presented. Parents assimilated practical and instructive messages, while children assimilated messages about weight loss and weight gain. Parents and children recognised that the campaigns were asking individuals to take personal responsibility for their weight status, and were at times critical that the campaigns did not tackle the broader issues associated with the causes and consequences of obesity. The lack of practical tools to encourage behavioural change was a key barrier for obese parents. CONCLUSIONS: Well-funded, targeted social marketing campaigns will play an important role in the prevention and management of obesity. It is important that these campaigns are comprehensively evaluated and are backed up with structural supports to enable and encourage population subgroups to act upon messages.

Nutrition advice during pregnancy: do women receive it and can health professionals provide it?

A healthy diet during pregnancy is essential for normal growth and development of the foetus. Pregnant women may obtain nutrition information from a number of sources but evidence regarding the adequacy and extent of this information is sparse. A systematic literature review was conducted to identify sources of nutrition information accessed by pregnant women, their perceived needs for nutrition education, the perceptions of healthcare providers about nutrition education in pregnancy, and to assess the effectiveness of public health programs that aim to improve nutritional practices. The Scopus data base was searched during January, 2013 and in February 2014 to access both qualitative and quantitative studies published between 2002 and 2014 which focused on healthy pregnant women and their healthcare providers in developed countries. Articles were excluded if they focused on the needs of women with medical conditions, including obesity, gestational diabetes or malnutrition. Of 506 articles identified by the search terms, 25 articles were deemed to be eligible for inclusion. Generally, women were not receiving adequate nutrition education during pregnancy. Although healthcare practitioners perceived nutrition education to be important, barriers to providing education to clients included lack of time, lack of resources and lack of relevant training. Further well designed studies are needed to identify the most effective nutrition education strategies to improve nutrition knowledge and dietary behaviours for women during antenatal care.

Identification and evaluation of models of antenatal care in Australia--a review of the evidence.

BACKGROUND: Antenatal care has been routine practice throughout the world since early in the 20th century, and in most developed countries, antenatal care consists of a scheduled program of individual consultations with a healthcare practitioner, using a doctor or midwife. Women seek antenatal care that provides a physical review of the health and development of their unborn baby, the reassurance and ability to be listened to and the opportunity for their partner to be involved in their care. AIMS: To identify the types of antenatal care services that are available to Australian women and investigate the views and opinions of Australian women related to these services. MATERIALS AND METHODS: A systematic literature review using Scopus and Medline databases was used to find appropriate journal articles in January 2013. Articles were restricted to those in the Australian setting from the past 10 years with a focus on different models of antenatal care and the views and experiences of women during their antenatal care. RESULTS: Eighteen relevant peer-reviewed journal articles were included. Emerging forms of antenatal care that are showing increasing levels of satisfaction from Australian women include continuity of carer, the midwifery-led care and group- or community-led care. These approaches are proving to be safe and successful. CONCLUSION: Newer models of antenatal care in Australia may offer benefits over standard practice.

Creating Food Learning Opportunities for Adults Within Urban Settings: A Framework for Food Pedagogies.

Globally, food is acknowledged as a primary focus for addressing challenges facing cities. City councils create and support food-related policies or strategies to enhance healthy and sustainable environments, and multiple food practitioners engage closely with these initiatives. However, the visibility of educational aspects of food within governments, policy development, public spaces, or across society is limited. There is a lack of evidence about how pedagogical frameworks can inform these initiatives. This study aims to develop a draft food pedagogies framework, whose application can inform food initiatives beyond the classroom to increase adults' awareness of, engagement with and empowered action relating to food, with the goal to advance societal health and sustainability. A qualitative approach included semi-structured interviews with 39 experienced food leaders from diverse food-related fields in Australia. Using thematic analysis, five key themes to assist adults learn about food in everyday life settings were identified: (1) Making use of (in)formal pedagogical spaces in communities; (2) Encouraging interactions with a range of people related to food; (3) Creating enjoyable and practical experiences as part of daily lives; (4) Developing supportive and transparent systems that reflect communities' needs; and (5) Utilizing broader social issues. A proposed framework, based on the five themes and existing theoretical frameworks, can be used to inform policy makers and diverse food practitioners to develop urban food strategies that aim to create food-centred changes within urban settings toward societal health and sustainability.

Improvement in iodine status of pregnant Australian women 3 years after introduction of a mandatory iodine fortification programme.

INTRODUCTION: In order to address population-level mild iodine deficiency in Australia, a mandatory iodine fortification programme of salt used in bread was introduced in late 2009. METHODS: A before-after study was conducted to assess changes in median urinary iodine concentration (MUIC) measurements, according to supplement use, in convenience samples of pregnant women attending a public antenatal clinic in a regional area of New South Wales, Australia in 2008 (n=139), 2011 (n=147) and 2012 (n=114). Knowledge and practices related to iodine nutrition were investigated in 2012, using self-administered questionnaires. RESULTS: The mild iodine deficiency confirmed pre-fortification (MUIC (IQR)=87.5 (62-123.5; n=110)) has steadily improved to 145.5 µg/L (91-252) in 2011 (n=106) and 166 (97-237) in 2012 (n=95) (sufficiency ≥ 150 µg/L). However, only women taking supplements containing iodine had MUIC indicative of sufficiency in both years surveyed post fortification (2011: 178 µg/L vs. 109 µg/L, P<0.001; 2012: 202 µg/L vs. 124 µg/L, P<0.05). Despite bread being the vehicle for iodine fortification, dairy foods remained major contributors to total iodine intake (58%). Overall knowledge regarding health implications of iodine deficiency was poor. CONCLUSIONS: Iodine status of women has improved since the introduction of mandatory iodine fortification; however supplementation is indicated during pregnancy.

Using interviews and peer pairs to better understand how school environments affect young children's playground physical activity levels: a qualitative study.

School break times provide a daily opportunity for children to be active; however, research indicates this time is underutilized. Reasons for low children's playground activity levels have primarily focused on physical barriers. This research aimed to contribute to physical environmental findings affecting children's playground physical activity levels by identifying additional variables through the interview process. Thirteen public schools were included in the sample (total 2946 children). Physical activity and environmental data were collected over 3 days. Environmental variables were manually assessed at each of the 13 schools. Observational data were used to determine which three schools were the most and least active. The principal, three teachers and 20 students in Grades 4-6 from these six schools (four lower and two average socioeconomic status) were invited to participate in the interview process. Student interviews involved the paired interview technique. The main themes generated from the school interviews included the effect of non-fixed equipment (including balls), playground markings, playground aesthetics, activity preference, clothing, the amount of break time available for play, teacher playground involvement, gender, bullying, school policies, student confidence in break-time activity and fundamental movement skills. The effect of bullying on playground physical activity levels was concerning.

Derailing healthy choices: an audit of vending machines at train stations in NSW.

ISSUE ADDRESSED: Train stations provide opportunities for food purchases and many consumers are exposed to these venues daily, on their commute to and from work. This study aimed to describe the food environment that commuters are exposed to at train stations in NSW. METHODS: One hundred train stations were randomly sampled from the Greater Sydney Metropolitan region, representing a range of demographic areas. A purpose-designed instrument was developed to collect information on the availability, promotion and cost of food and beverages in vending machines. Items were classified as high/low in energy according to NSW school canteen criteria. RESULTS: Of the 206 vending machines identified, 84% of slots were stocked with high-energy food and beverages. The most frequently available items were chips and extruded snacks (33%), sugar-sweetened soft drinks (18%), chocolate (12%) and confectionery (10%). High energy foods were consistently cheaper than lower-energy alternatives. CONCLUSIONS: Transport sites may cumulatively contribute to excess energy consumption as the items offered are energy dense. Interventions are required to improve train commuters' access to healthy food and beverages.

Identifying barriers and facilitators in the development and implementation of government-led food environment policies: a systematic review.

CONTEXT: Policy-specific actions to improve food environments will support healthy population diets. OBJECTIVE: To identify cited barriers and facilitators to food environment policy (FEP) processes reported in the literature, exploring these according to the nature of the policy (voluntary or mandatory) and country development status. DATA SOURCES: A systematic search was conducted of 10 academic and 7 grey-literature databases, national websites, and manual searches of publication references. DATA EXTRACTION: Data on government-led FEPs, barriers, and facilitators from key informants were collected. DATA SYNTHESIS: The constant-comparison approach generated core themes for barriers and facilitators. The appraisal tool developed by Hawker et al. was adopted to determine the quality of qualitative and quantitative studies. RESULTS: A total of 142 eligible studies were identified. Industry resistance or disincentive was the most cited barrier in policy development. Technical challenges were most frequently a barrier for policy implementation. Frequently cited facilitators included resource availability or maximization, strategies in policy process, and stakeholder partnership or support. CONCLUSIONS: The findings from this study will strategically inform health-reform stakeholders about key elements of public health policy processes. More evidence is required from countries with human development indices ranging from low to high and on voluntary policies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42018115034.

Building Public Health Capacity through Organizational Change in the Sport System: A Multiple-Case Study within Australian Gymnastics.

Sports clubs increasingly are settings for health promotion initiatives. This study explored organizational change processes and perceived facilitators and barriers relevant to implementing a health promotion initiative within gymnastics settings in New South Wales (NSW), Australia. A multiple-case design investigated the experiences of the state association (Gymnastics NSW) and five clubs from one region of NSW in a participatory Health-Promoting Gymnastics Clubs (HPGC) program. The program aimed to build the capacity of Gymnastics NSW to support affiliated clubs to become health-promoting settings. Interviews with organizational representatives explored their experiences of the program and identified factors that enabled or inhibited program adoption, implementation and sustainability. Facilitators and barriers identified included leadership and champions; organizational capacity and culture; priorities and timing; and characteristics of the HPGC framework. This multi-level, organizational change intervention demonstrated potential to create health-promoting gymnastics settings. Tailoring strategies in diverse club contexts required involvement of organizational leaders in program development and action planning. Despite positive impacts, pre-existing organizational culture inhibited integration of health promotion as a core value. Sustained organizational change may result from professional regulatory requirements (e.g., accreditation and affiliation), and policy directives and funding (for organizational change, not program delivery) from relevant government departments.

A Food Insecurity Systematic Review: Experience from Malaysia.

Living free from hunger is a basic human right. However, some communities still experience household food insecurity. This systematic literature review explored different aspects of household food insecurity in Malaysia including vulnerable groups, prevalence, risk factors, coping strategies, and the consequences of food insecurity. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Thirty-three relevant articles were selected from scientific databases such as CINAHL, Pubmed and Google Scholar, scrutiny of reference lists, and personal communication with experts in the field. The prevalence of household food insecurity in Malaysia was unexpectedly reported as high, with affected groups including Orang Asli, low-income household/welfare-recipient households, university students, and the elderly. Demographic risk factors and socioeconomic characteristics included larger household, living in poverty, and low education. Coping strategies were practices to increase the accessibility of food in their households. Consequences of household food insecurity included psychological, dietary (macro- and micronutrient intakes), nutritional status, and health impacts. In conclusion, this review confirmed that household food insecurity in Malaysia continues to exist. Nevertheless, extensive and active investigations are encouraged to obtain a more holistic and comprehensive picture pertaining to household food security in Malaysia.

Policy Inertia on Regulating Food Marketing to Children: A Case Study of Malaysia.

Unhealthy food marketing shapes children's preference towards obesogenic foods. In Malaysia, policies regulating this food marketing were rated as poor compared to global standards, justifying the need to explore barriers and facilitators during policy development and implementation processes. The case study incorporated qualitative methods, including historical mapping, semi-structured interviews with key informants and a search of cited documents. Nine participants were interviewed, representing the Federal government (n = 5), food industry (n = 2) and civil society (n = 2). Even though the mandatory approach to government-led regulation of food marketing to children was the benchmark, more barriers than facilitators in the policy process led to industry self-regulations in Malaysia. Cited barriers were the lack of political will, industry resistance, complexity of legislation, technical challenges, and lack of resources, particularly professional skills. The adoption of industry self-regulation created further barriers to subsequent policy advancement. These included implementer indifference (industry), lack of monitoring, poor stakeholder relations, and policy characteristics linked to weak criteria and voluntary uptake. These underlying barriers, together with a lack of sustained public health advocacy, exacerbated policy inertia. Key recommendations include strengthening pro-public health stakeholder partnerships, applying sustained efforts in policy advocacy to overcome policy inertia, and conducting monitoring for policy compliance and accountability. These form the key lessons for advocating policy reforms.

Tracking Progress from Policy Development to Implementation: A Case Study on Adoption of Mandatory Regulation for Nutrition Labelling in Malaysia.

Mandatory nutrition labelling, introduced in Malaysia in 2003, received a "medium implementation" rating from public health experts when previously benchmarked against international best practices by our group. The rating prompted this qualitative case study to explore barriers and facilitators during the policy process. Methods incorporated semi-structured interviews supplemented with cited documents and historical mapping of local and international directions up to 2017. Case participants held senior positions in the Federal government (n = 6), food industry (n = 3) and civil society representations (n = 3). Historical mapping revealed that international directions stimulated policy processes in Malaysia but policy inertia caused implementation gaps. Barriers hindering policy processes included lack of resources, governance complexity, lack of monitoring, technical challenges, policy characteristics linked to costing, lack of sustained efforts in policy advocacy, implementer characteristics and/or industry resistance, including corporate political activities (e.g., lobbying, policy substitution). Facilitators to the policy processes were resource maximization, leadership, stakeholder partnerships or support, policy windows and industry engagement or support. Progressing policy implementation required stronger leadership, resources, inter-ministerial coordination, advocacy partnerships and an accountability monitoring system. This study provides insights for national and global policy entrepreneurs when formulating strategies towards fostering healthy food environments.

Developing and testing a mobile application for breastfeeding support: The Milky Way application.

BACKGROUND: Supporting women to continue breastfeeding is a global challenge. The Milky Way Program is an effective face to face intervention to increase breastfeeding rates up to six months postpartum. The sustainability and access to the Milky Way Program could be enhanced by transforming it into a mobile application allowing women to access relevant information from their own place at a convenient time. AIM: To explore the process of transforming the Milky Way Program into an acceptable and usable mobile health application. METHOD: Stakeholders including multidisciplinary researchers and end-users designed the application based on the Milky Way Program by using Persuasive System Design principles. A mixed-method approach was used in the development and evaluation process. Seven women were recruited through convenience sampling to pilot test the application. The women's feedback was collected through an online survey six weeks after birth and individual interviews at four months postpartum. FINDINGS: Women in the pilot study reported that the breastfeeding application was well designed, easy to use, interactive, reassuring and evidence-based with credible sources of information. CONCLUSION: The Persuasive System Design model combined with end-user engagement can feasibly inform the development of an acceptable and usable mobile health application for breastfeeding based on a proven clinical intervention. Further rigorous testing is required to evaluate the effectiveness of the application on breastfeeding initiation and duration.