Experiences of healthcare practitioners providing nutrition care to people with cancer in New Zealand: A qualitative study.

Aim: To explore the perspectives and experiences of healthcare practitioners in providing nutrition care to people with cancer in New Zealand. Methods: Semi-structured interviews were conducted with 16 New Zealand healthcare professionals (HCPs) practicing in specialist secondary and tertiary cancer care (both public and private) who had previously completed an online survey about nutrition in cancer care. Interviews were recorded and transcribed verbatim, and thematic analysis was undertaken. Results: Participants identified nutrition as important in cancer care, from diagnosis to survivorship, in order to maximise recovery and ongoing health. While participants reported that the best person to provide high-quality individualised nutrition care is a dietitian, other HCPs also have a role in nutrition care. Limited nutrition care is currently available, especially for those in rural areas, which impacts health and equity in cancer care. Participants identified a need for increased dietitian capacity in the workforce as well as a need for nutrition resources that were accessible and appropriate. Conclusion: The perspective of participants was that more must be done to provide nutrition care as part of cancer care in New Zealand to improve health and wellbeing among people with cancer.

Adjusting the Iodine Content of Iodized Salt to Meet the Recommended Intake for Females of Reproductive Age: A Simulation Study with a Reduced Sodium Scenario.

BACKGROUND: The use of iodized salt is a key strategy to increase iodine intake worldwide. In many countries, including New Zealand, females of reproductive age are still at risk of being mildly iodine deficient. OBJECTIVE: This study aimed to determine the level of iodization of salt needed to ensure that females aged 18 to 40 y have an adequate intake of iodine in 2 scenarios: current discretionary salt intake and reduced discretionary salt intake. METHOD: Data from nonpregnant, nonlactating females aged 18 to 40 y (n = 795) who took part in the 2008/09 New Zealand Adult Nutrition Survey and completed a 24-h dietary recall were used. Iodine intake was determined from all foods except bread and discretionary salt, which are fortified with iodine. Iodine from bread and salt was estimated at different levels of salt iodization, starting at 25 mg iodine/kg salt and increasing incrementally by 5 mg/kg, and added to calculate total iodine intake. The simulation concluded when the appropriate iodine content in salt was found using the estimated average requirement (EAR) cut-point method. RESULTS: In the 2 scenarios, current discretionary salt intake (i.e., 400 mg/d) and reduced discretionary salt intake (i.e., 304 mg/d), the iodine concentration of salt is required to be 55 mg/kg and 70 mg/kg for no more than 2% of females to have an iodine intake below the EAR of 100 µg of iodine/d, respectively. In both scenarios and at all levels of iodine concentration, no one was above the upper level of intake of iodine of 1100 µg/d. CONCLUSIONS: This study found that females of reproductive age need to consume iodized salt at the higher end of the legislated range of 25 to 65 mg/kg. If strategies to reduce sodium intake were adopted, the range would need to increase, or iodized salt would need to be included in a wider range of staple foods.

Trends in BMI of Indonesian adults between 1993 and 2014: a longitudinal population-based study.

OBJECTIVE: To examine the trajectories of BMI in Indonesian adults from 1993 to 2014, investigating different patterns by sex and birth cohort. DESIGN: Longitudinal study: secondary data analysis of the Indonesian Family Life Survey, a large-scale population-based longitudinal study, had their height and weight measured up to five times throughout the 21-year study period (1993-2014). The change in BMI across time was estimated using group-based trajectory models, then differences by sex and birth cohort were investigated using random effect (mixed) models. SETTING: Thirteen out of twenty-seven provinces in Indonesia. PARTICIPANTS: Indonesian adults aged 19 years and older (n 42 537) were included in the analysis. RESULTS: Mean BMI in adults increased between 1993 (21·4 kg/m2) and 2014 (23·5 kg/m2). The group-based trajectory model found three distinct groups with mean BMI increasing more rapidly in the most recent time periods. The first group (56·7 % of participants) had a mean BMI entirely within the normal weight range; the second group (34·7 %) started in the normal weight category and were obese, on average by the end of the study period; and the third group (8·6 %) were always in the obese category, on average. The shape of these three trajectories differed by gender (P < 0·001) and birth cohort (P < 0·001). CONCLUSIONS: The mean BMI among Indonesian adults has increased between 1993 and 2014, driven by those in the most recent birth cohorts. Our findings support the urgent need for targeted overweight and obesity prevention and intervention programmes in Indonesia.

National Sporting Organisation policies: A health promotion opportunity?

ISSUE ADDRESSED: The objective was to identify whether National Sporting Organisations (NSOs) have policy documentation on healthy behaviours (smokefree, sun-protection, healthy food/beverages and alcohol) and, for organisations with such documentation, whether this was in-line with current scientific evidence of past best practice in cancer prevention. METHODS: This cross-sectional policy analysis study was performed September to December 2018 in Aotearoa/New Zealand. A content analysis was undertaken using NSO policy documents matched against a framework of key indicators for best practice within health behaviours of interest. Data analysis of the policy process was undertaken through key informant telephone interviews with NSO staff using semi-structured qualitative interviews. RESULTS: Of 96 NSOs, nearly half (49%) mentioned smokefree at least once in one of their policy documents, and 47% had an alcohol policy, although in both instances the policies lacked comprehensiveness. Two NSOs had a reasonably comprehensive sun protection policy. Seventeen had at least one specific nutrition policy/guideline. The contents of the latter were primarily related to short-term athletic performance rather than non-communicable disease prevention, specifically promoting hydration during sports participation, and food and nutrition to support sporting performance. Two NSOs had policies relating to the promotion of healthy food/nutrition more widely. For some NSOs, the lack of health-related policies was not a conscious choice but just not considered previously. Other NSOs reported they lacked resources or had other priorities. CONCLUSIONS: Although this study clearly demonstrates that many NSOs lack adequate health-related policies, this is not necessarily a conscious choice, but the result of a lack of resources, other priorities, or just that they had not considered developing policies in these areas. A number expressed support for these types of policies although it was apparent that some, particularly smaller NSOs, would require assistance in policy template development. It seems probable that the development of health-related policies will only occur if partner agencies become involved.

Incorporating a gender lens into nutrition and health-related policies in Fiji: analysis of policies and stakeholder perspectives.

BACKGROUND: Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. METHODS: This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. RESULTS: Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. CONCLUSIONS: There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji.

Sodium in the New Zealand diet: proposed voluntary food reformulation targets will not meet the WHO goal of a 30% reduction in total sodium intake.

PURPOSE: To simulate the potential impact of the HeartSAFE 2020 programme, a food reformulation initiative by the New Zealand (NZ) Heart Foundation, on sodium intake in the NZ adult population. METHODS: A representative sample of NZ adults aged 15 years and older completed a 24-h diet recall survey, with 25% of participants completing a second diet recall, in the 2008/09 New Zealand Adult Nutrition Survey (n = 4721). These data were used to estimate sodium intakes of participants. The effect of altering the sodium content of 840 foods in 17 categories and 35 sub-categories included in the NZ HeartSAFE 2020 programme was simulated. The simulated sodium intake reductions in each food sub-category for the entire sample were calculated. Using sampling weights, simulated reductions in population sodium intake and by sociodemographic subgroups were also analysed. RESULTS: Sodium intake from foods included in the HeartSAFE 2020 programme was 1307 mg/day (95% CI 1279, 1336) at baseline. After applying the HeartSAFE 2020 targets, potential sodium intake was 1048 mg/day (95% CI 1024, 1027). The absolute sodium reduction was 260 mg/day (95% CI 252, 268), corresponding to 20% sodium reduction for the foods included in the NZ HeartSAFE programme. CONCLUSION: Current sodium targets featured in the NZ HeartSAFE programme will not meet the 30% sodium intake reduction set out by the WHO Global Action Plan. A more comprehensive strategy consistent with the WHO SHAKE Technical Package is needed to advance the goal of sodium intake reduction.

Gender roles, generational changes and environmental challenges: an intersectional interpretation of perceptions on healthy diets among iTaukei women and men in Fiji.

OBJECTIVE: To investigate perceptions of iTaukei Fijian women and men around diet and the ability to consume a healthy diet. DESIGN: Six focus groups were conducted with women and men separately. Six to ten women and men participated in each group. Discussions were recorded, transcribed, translated and thematically analysed. Themes were mapped to an intersectionality framework to aid interpretation. SETTING: Four villages in Viti Levu, Fiji. PARTICIPANTS: Twenty-two women and twenty-four men. RESULTS: Seven overarching themes were identified, including generational changes in food behaviour, strong-gendered beliefs around food and food provision, cultural and religious obligations around food, the impact of environmental change on the ability to consume a healthy diet, perceptions of the importance of food, food preferences and knowledge. Participants across focus groups identified that it was the 'duty' of women to prepare food for their families. However, some women reflected on this responsibility being unbalanced with many women now in the formal workforce. Changes between generations in food preferences and practices were highlighted, with a perception that previous generations were healthier. Power dynamics and external factors, such as environmental changes, were identified by women and men as crucial influences on their ability to eat a healthy diet. CONCLUSION: Embedded traditional perceptions of gendered roles related to nutrition were misaligned with other societal and environmental changes. Given factors other than gender, such as broader power dynamics and environmental factors were identified as influencing diet, viewing nutrition-related issues through an intersectional lens is important to inform equitable food policy in Fiji.

Comment on Hogas et al. Salt, Not Always a Cardiovascular Enemy? A Mini-Review and Modern Perspective. Medicina 2022, 58, 1175.

Hogas et al. recently published their perspective on dietary salt in a mini review [...].

Change in mean salt intake over time using 24-h urine versus overnight and spot urine samples: a systematic review and meta-analysis.

BACKGROUND: Little is known about the capacity of overnight and spot urine samples to estimate changes in mean salt intake over time. The objective of this review was to compare the estimates of change in mean population salt intake based on 24-h urine and overnight/spot urine samples. METHODS: Studies were systematically identified through searches of peer-reviewed databases (Medline, Embase, Global Health, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews) and grey literature. Studies that reported estimates of mean salt intake for at least two time points based on both 24-h and overnight/spot urines were deemed eligible. The capacity of overnight/spot urine samples to estimate the change in mean salt intake was assessed both at the individual-study level and overall through random-effects meta-analyses. The level of heterogeneity was assessed through the I2 statistic. Subgroup and sensitivity analyses were conducted to explore possible sources of heterogeneity, and check the robustness of the findings from the primary analysis. RESULTS: A total of 1244 records were identified, 50 were assessed as full text, and 14 studies met the criteria, capturing data on 7291 participants from seven countries. Nine and five studies collected overnight and spot urines, respectively. The comparison of the change in mean salt intake between 24-h and overnight/spot urines showed some inconsistencies at the individual study-level. The pooled mean change in salt intake was - 0.43 g/day (95% CI - 1.16 to 0.30; I2 = 95%) using 24-h urines, and - 0.22 g/day (- 0.65 to 0.20; I2 = 87%) using overnight/spot urines, with a pooled difference-in-differences between the two methods of 0.27 g/day (- 0.23 to 0.77; I2 = 89%). Subgroup analyses showed substantial heterogeneity for most subgroups. Sensitivity analyses did not change the effect observed in the primary analysis. CONCLUSION: The evidence for the capacity of overnight/spot urines to estimate changes in mean salt intake over time is uncertain. More research where overnight/spot urines are collected in parallel with 24-h urines is needed to enable a more in-depth evaluation of these alternative approaches to estimating change in mean salt intake.

Urinary iodine concentration of New Zealand adults improves with mandatory fortification of bread with iodised salt but not to predicted levels.

PURPOSE: To measure the iodine status and iodine intake of New Zealand adults 18-64 years of age following mandatory fortification of bread with iodine. METHODS: A cross-sectional survey of NZ adults living in Dunedin and Wellington during February-November 2012. Three hundred and one men and women aged 18-64 years randomly selected from the New Zealand Electoral Roll completed a 24-h urine collection, a demographic and iodine-specific food frequency questionnaire (FFQ), and had height and weight measured. Urine collections were analysed for iodine and reported as median urinary iodine concentration (UIC) µg/L and median urinary iodine excretion (UIE) µg/day. The FFQ was used to estimate iodine intake with and without discretionary iodised salt use. RESULTS: The median UIC for all adults was 73 µg/L, indicative of mild iodine deficiency. The mean urinary volume was 2.0 L. As an estimate of iodine intake, the median UIE was 127 µg/day. Estimated iodine intake, using the FFQ which included discretionary iodised salt use, was 132 µg/day. Iodine intakes were associated with UIC (P = 0.040) and UIE (P = 0.003), but not with bread iodine intake and iodised salt use. CONCLUSION: Using the WHO/UNICEF/ICCIDD target for iodine sufficiency (a UIC of >100 µg/L) based on school-aged children with a mean urinary volume of 1.0 L, the iodine status of NZ adults does not reach adequate levels (73 µg/L). A more realistic parameter in a population with a higher urinary volume excretion (2.0 L) is the UIE. A median UIE of 127 µg/day suggests that the iodine status of NZ adults is now likely to be adequate.

Sodium in commonly consumed fast foods in New Zealand: a public health opportunity.

OBJECTIVE: (i) To determine the Na content of commonly consumed fast foods in New Zealand and (ii) to estimate Na intake from savoury fast foods for the New Zealand adult population. DESIGN: Commonly consumed fast foods were identified from the 2008/09 New Zealand Adult Nutrition Survey. Na values from all savoury fast foods from chain restaurants (n 471) were obtained from nutrition information on company websites, while the twelve most popular fast-food types from independent outlets (n 52) were determined using laboratory analysis. Results were compared with the UK Food Standards Agency 2012 sodium targets. Nutrient analysis was completed to estimate Na intake from savoury fast foods for the New Zealand population using the 2008/09 New Zealand Adult Nutrition Survey. SETTING: New Zealand. SUBJECTS: Adults aged 15 years and above. RESULTS: From chain restaurants, sauces/salad dressings and fried chicken had the highest Na content (per 100 g) and from independent outlets, sausage rolls, battered hotdogs and mince and cheese pies were highest in Na (per 100 g). The majority of fast foods exceeded the UK Food Standards Agency 2012 sodium targets. The mean daily Na intake from savoury fast foods was 283 mg/d for the total adult population and 1229 mg/d for fast-food consumers. CONCLUSIONS: Taking into account the Na content and frequency of consumption, potato dishes, filled rolls, hamburgers and battered fish contributed substantially to Na intake for fast-food consumers in New Zealand. These foods should be targeted for Na reduction reformulation.

Tick front-of-pack label has a positive nutritional impact on foods sold in New Zealand.

OBJECTIVE: Nutritional impact of the Tick front-of-pack labelling programme was evaluated by investigating nutrient changes to the purchased food supply and the nutritional quality of Tick v. non-Tick products. Factors influencing manufacturers' decisions to develop and license Tick products were also explored. DESIGN: Observational, cross-sectional and change over time data. SETTING: New Zealand food supply, 2011-2013. SUBJECTS: Forty-five newly licensed Tick products from five food categories were analysed: Edible Oil Spreads, Yoghurt & Dairy Desserts, Frozen Desserts, Ready Meals and Processed Poultry. Four manufacturers of these products were interviewed. RESULTS: Eligible products (31 % of all Tick products in these categories) removed 4·1 million megajoules of energy, 156·0 tonnes of saturated fat, 15·4 tonnes of trans-fat and 4·0 tonnes of sodium from food products sold in New Zealand over three years. In each food category, these Tick products were, on average, 14-76 % lower in energy, saturated fat, trans-fat and sodium than non-Tick products, indicating healthier options. Participating manufacturers reported that international market trends and consumer demand for tasty, healthy foods primarily influenced Tick product development and sales. Tick was used as part of their marketing strategy as it was perceived as a credible, well-recognised logo for New Zealand consumers. Tick was cited as the primary initiative encouraging saturated fat reduction. CONCLUSIONS: The Tick Programme is continuing to encourage manufacturers to make meaningful improvements to the nutritional quality of the New Zealand food supply. Over time, these changes are likely to influence population nutrient intakes and reduce CVD risk factors.

Sodium reduction in New Zealand requires major behaviour change.

This pilot study examined the feasibility of adherence to a low sodium diet in a sample of healthy New Zealand adults. It also addressed whether following a low sodium diet was accompanied by changes in intakes of other nutrients that influence cardiovascular risk. Eleven healthy adults provided dietary intake data and a 24-hour urine collection at baseline and follow-up. They then received nutritional counselling based on the World Health Organization recommendation for sodium intake (<2000 mg/day) and received ongoing nutritional support while undertaking a low sodium diet for four weeks. At the end of the four-week period, participants completed a semi-structured interview that elicited participants' opinions on barriers and facilitators to following a low sodium diet and explored changes in participants' dietary habits and behaviours. Thematic analysis revealed that adherence to a low sodium diet required substantial changes to participants' usual food purchasing and preparation habits. Participants reported that lack of control over the sodium content of meals eaten away from the home, the complex and time-consuming nature of interpreting nutrition information labels, and difficulty identifying suitable snacks were barriers to adherence. Detailed meal planning and cooking from scratch, using flavour replacements, reading food labels to identify low sodium foods, receiving support from other people and receiving tailored nutrition advice were facilitators. Mean sodium intake reduced over the period, accompanied by a decrease in mean intake of total fat. These factors suggest that sodium reduction in New Zealand adults was feasible. However, considerable changes to eating behaviours were required.

Sodium and nutrition labelling: a qualitative study exploring New Zealand consumers' food purchasing behaviours.

OBJECTIVE: Dietary sodium reduction is an important public health intervention that would reduce blood pressure and chronic disease. An understanding of how New Zealand consumers' food purchasing behaviour is influenced by perceptions of dietary sodium will inform future sodium-reduction strategies. DESIGN: The present qualitative study used in-depth interviews of adult consumers to explore consumer knowledge, understanding of food labels and food purchasing behaviour with respect to dietary sodium. SETTING: New Zealand. SUBJECTS: A convenience sample of sixteen adult grocery shoppers. RESULTS: A thematic analysis of the transcripts showed New Zealand consumers lacked the background knowledge necessary to understand and regulate their own salt intake and were unable to interpret existing food labels with respect to dietary salt. CONCLUSIONS: The findings add further weight to calls for food labels that do not require background knowledge or numerical skills and highlight the need for population-based public health interventions. Education of New Zealand consumers on the health benefits of sodium reduction and how this may be achieved would complement this approach.

Consuming calories and creating cavities: beverages NZ children associate with sport.

Sugar-sweetened beverages (SSBs) are widely available, discounted and promoted, and despite recommendations to the contrary, frequently consumed by children. They provide few nutritional benefits, and their consumption is implicated in a number of poor health outcomes. This study examined the nature of the beverages that sport-playing New Zealand (NZ) children associate with sport. It assessed how well the beverages aligned with nutrition guidelines and relevant regulations, and their likely impacts on health. Eighty-two children (38 girls and 44 boys) aged 10-12 years were purposively selected from netball, rugby and football clubs in low and high socioeconomic neighbourhoods, in Wellington, New Zealand (NZ). Children photographed beverages they associated with sport. The beverages were then purchased and analysed in accordance with NZ nutrition guidelines, and relevant content and labelling regulations, by: package and serving size; energy, sugar, sodium and caffeine content; pH; and advisory statements. The beverages the children associated with sport overwhelmingly had characteristics which do not support children in adhering to NZ nutrition guidelines. Implementing public health mechanisms, such as healthy food and beverage policies, widely promoting water as the beverage of choice in sport, and implementing healthy eating and drinking campaigns in sports clubs, would assist children who play organised sport to select beverages that are in keeping with children's nutrition guidelines. As part of a comprehensive public health approach they would also reduce the substantial, unnecessary and potentially harmful contribution sugar-sweetened beverages make to their diet.

Salt Substitutes-An Important Tool to Increase Potassium and Reduce Sodium Intakes?

Potassium is an essential mineral and is the main cation in intracellular fluid [...].

Measuring Sodium from Discretionary Salt: Comparison of Methods.

(1) Background: The best method to assess discretionary salt intake in population surveys has not been established. (2) Methods: This secondary analysis compared three different methods of measuring sodium intake from discretionary salt in a convenience sample of 109 adults in New Zealand. Participants replaced their household salt with lithium-tagged salt provided by researchers over eight days. Baseline 24 h urine was collected, and two further 24 h urine and 24 h dietary recalls were collected between days six and eight. Discretionary salt was estimated from the lithium-tagged salt, focused questions in the 24 h dietary recall, and the 'subtraction method' (a combination of 24 h urine and 24 h dietary recall measures). (3) Results: Around one-third of estimates from the 'subtraction method' were negative and therefore unrealistic. The mean difference between 24 h dietary recall and lithium-tagged salt estimates for sodium from discretionary salt mean were 457 mg sodium/day and 65 mg/day for mean and median, respectively. (4) Conclusions: It is possible to obtain a reasonable estimate of discretionary salt intake from careful questioning regarding salt used in cooking, in recipes, and at the table during a 24 h recall process to inform population salt reduction strategies.