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.

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.

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.

Evaluating return on investment in a school based health promotion and prevention program: the investment multiplier for the Stephanie Alexander Kitchen Garden National Program.

Successful health promotion and disease prevention strategies in complex community settings such as primary schools rely on acceptance and ownership across community networks. Assessing multiplier impacts from investment on related community activity over time are suggested as key alongside evidence of program health effects on targeted groups of individuals in gauging community network engagement and ownership, dynamic impacts, and program long term success and return on investment. An Australian primary school based health promotion and prevention strategy, the Stephanie Alexander Kitchen Garden National Program (SAKGNP), which has been providing garden and kitchen classes for year 3-6 students since 2008, was evaluated between 2011 and 2012. Returns on Australian Federal Government investment for school infrastructure grants up to $60,000 are assessed up to and beyond a two year mutual obligation period with: (i) Impacts on student lifestyle behaviours, food choices and eating habits surveyed across students (n = 491 versus 260) and parents (n = 300 versus 234) in 28 SAKGNP and 14 matched schools, controlling for school and parent level confounders and triangulated with SAKGNP pre-post analysis; (ii) Multiplier impacts of investment on related school and wider community activity up to two years; and (iii) Evidence of continuation and program evolution in schools observed beyond two years. SAKGNP schools showed improved student food choices (p = 0.024) and kitchen lifestyle behaviour (p = 0.019) domains compared to controls and in pre-post analysis where 20.0% (58/290) reported eating fruit and vegetables more often and 18.6% (54/290) preparing food at home more often. No significant differences were found in case control analysis for eating habits or garden lifestyle behaviour domains, although 32.3% of children helped more in the garden (91/278) and 15.6% (45/289) ate meals together more often in pre-post analysis. The multiplier impact on total community activity up to two years was 5.07 ($226,737/$44,758); 1.60 attributable to school, and 2.47 to wider community, activity. All 8 schools observed beyond two years continued garden and kitchen classes, with an average 17% scaling up and one school fully integrating staff into the curriculum. In conclusion evidence supports the SAKGNP to be a successful health promotion program with high community network impacts and return on investment in practice.

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.

Observing children's playground activity levels at 13 Illawarra primary schools using CAST2.

BACKGROUND: Declining levels of children's physical activity may contribute to Australia's increasing childhood obesity epidemic. School recess is an underutilized opportunity to increase children's physical activity. METHODS: Thirteen regional Australian public primary schools participated in the study (2946 children). The Children's Activity Scanning Tool 2 (CAST2) collected observational playground physical activity data. The research also addressed: length of break, socioeconomic status (SES), gender, number of scanning days, and instrument calibration. RESULTS: The proportions of Moderate or Vigorous Physically Activity (MVPA) children at the observed schools ranged from 0.4 to 0.7. The odds ratio of boys being MVPA relative to girls ranged from 0.8581 to 2.137. There were significant differences between the mean proportions of 3 days of activity (range P = .001 to P = .015) and no association between SES school groupings (deviance ratio: 0.48; P = .503). Interrater reliability for instrument calibration using Spearman correlations coefficients ranged from r = .71 to r = .99. CONCLUSIONS: There were significant differences between proportions of MVPA children at the 13 schools and between male and female populations. There was no association between playground physical activity and SES. The monitoring period for CAST2 should be at least 3 days. Interrater reliability indicates that correlations between observers were consistently high.

Action or inaction? Food and nutrition in Australian local governments.

OBJECTIVE: To determine the current level of activity of Australian local governments in twenty-nine food and nutrition action areas and whether the level of activity had changed between 1995 and 2007. DESIGN: A cross-sectional study utilising a postal survey was undertaken of all local governments in Australia. The same instrument and protocol were used in 1995 and 2007. SETTING: Australian local governments. RESULTS: Local governments in Australia continue to be engaged in food and nutrition activities. This involvement has constricted in range in the last 12 years but higher levels of engagement are reported for several areas. The levels of involvement of local governments in the different states varied significantly, with Victoria reporting higher levels of involvement in several areas, particularly in food and nutrition activities related to community services. Local governments in New South Wales and Western Australia reported significantly lower levels of involvement in food and nutrition activities. Several factors may have contributed to these differences, including availability of resources and support, mandatory requirements by state governments, different attitudes of General Managers and staff and availability of funds for special projects. CONCLUSIONS: If Australian local governments are to be recognised and supported for their involvements in food and nutrition activities, more in-depth research is required to elucidate the factors that act as barriers or facilitate their on-going involvement in this important area. Support for local governments in rural areas to become or remain engaged in food matters should receive special consideration.

Women's awareness of the importance of long-chain omega-3 polyunsaturated fatty acid consumption during pregnancy: knowledge of risks, benefits and information accessibility.

OBJECTIVE: To evaluate pregnant women's knowledge regarding the importance of long-chain omega-3 polyunsaturated fatty acids (LC n-3 PUFA) consumption during pregnancy and assess their views on current information availability. DESIGN: A 27-item demographic and food safety/behaviour questionnaire was administered to pregnant women during their antenatal clinic visits. chi2 tests were performed using SPSS. SETTING: Antenatal clinics at two regional hospitals in New South Wales, Australia. SUBJECTS: One hundred and ninety (n 190) pregnant women. RESULTS: Three quarters of the women had not received information regarding LC n-3 PUFA. Approximately half of the women were aware of issues relating to LC n-3 PUFA; however, their knowledge was limited, with most obtaining their knowledge from books and magazines. Women generally had low (30 %, 29 %) to moderate (28 %, 24 %) levels of concern about LC n-3 PUFA and mercury, respectively. CONCLUSIONS: Pregnant women lack knowledge of LC n-3 PUFA and health-care services do not provide pregnant women with adequate information on the importance of eating foods high in LC n-3 PUFA during pregnancy.

Nutrition function, health and related claims on packaged Australian food products--prevalence and compliance with regulations.

Australia and New Zealand are currently reviewing the regulations governing nutrition function, health and related claims on foods. Health claims currently are not permitted on food labels, with one exception. The aim of this study was to describe the use of such claims on packaged food for sale in Australia (excluding nutrient content claims) prior to any changes to the regulations, and measure compliance with existing regulations. A survey was conducted of the labelling of 7850 products (including multiple pack sizes of individual foods) in 47 different food categories on sale in New South Wales in 2003. A total of 2098 nutrition function, health or related claims and 12 therapeutic claims were recorded. Fourteen percent of products carried some sort of claim. If nutrient function and general health maintenance claims are excluded, 8.1% of products carried a health or related claim. Using the claims categorisation proposed by Food Standards Australia New Zealand for a new standard on claims, general-level claims were found on 9.8% of products and high-level and therapeutic claims (illegal at the time) on 1.2%. The food categories with the highest proportion of products carrying claims were sports drinks (92%), energy drinks (84%), sports bars (57%) and breakfast cereals (54%). 118 high-level and therapeutic claims did not conform to current food standards and there were many general-level claims for ingredient benefits that were unlikely to be able to be scientifically substantiated. The results of this survey suggest that more than 5% of claims were not complying with the current regulations and that the standards were not being fully enforced. To be effective, the new standard will need to be accompanied by clear guidelines for manufacturers on requirements for substantiating claims. Comprehensive education and enforcement frameworks also will be needed, to reduce the number of illegal or apparently unsubstantiated claims.

Nutrition and related claims used on packaged Australian foods--implications for regulation.

The aim of this study was to describe the use of nutrition and related claims on packaged food for sale in Australia and measure the compliance of such claims with regulations governing their use. A survey was conducted of the labelling of 6662 products in 40 different food categories on sale in New South Wales in 2001. Levels of compliance were assessed by comparing the claims on the label and data in the nutrition information panel with requirements of the Foods Standards Code and the Code of Practice on Nutrient Claims. Half of the products (51.3%) carried some type of nutrition related claim and 36.2% made at least one nutrient claim, with an average of 1.2 nutrition related claims on every food product. The foods with the highest use of nutrient claims were sports drinks, breakfast cereals, meat substitutes, pretzels and rice cakes, muesli bars and yoghurt. The most common nutrient claims were for fat, cholesterol, vitamins, minerals, and sugar. More than 20% of products carried claims related to additives. Many nutrient claims (12.9%) did not comply with current regulations, especially those in the voluntary Code of Practice. Adoption of mandatory requirements for all claims within the Food Standards Code may improve the levels of compliance. Implications for the regulation of nutrition and related claims are discussed. The impact of nutrition claims on consumer purchasing and consumption behaviour deserves further study.