Consumer perceptions of nutrient content claims in Australia: A qualitative study.

BACKGROUND: Nutrition and health claims influence consumer purchasing. Claims include content claims, which refer to the amount of a nutrient contained in a product, and health claims, which refer to health benefits of foods or nutrients in a product. Products that display a health claim must meet the Nutrient Profiling Scoring Criterion (NPSC). The present study aimed to explore consumer perceptions of content claims used on food and beverage labelling and advertisements. METHODS: Semi-structured focus groups were conducted with Australian consumers. Analysis involved an inductive, reflexive approach to thematic analysis. RESULTS: Six focus groups involving 26 participants were conducted. Four main interconnected themes were generated: (1) complex factors influence food choice; (2) content claim scepticism; (3) the difference between content and health claims is unclear; and (4) the regulation of content claims is not common knowledge. Content claims were used, although generally viewed through a lens of scepticism and mistrust, and seen as a promotional tool for the food industry. Product complexity appeared to increase content claim use as a result of consumer uncertainty of the content of complex products, such as ultraprocessed foods. Most participants were aware that content and health claims were in some way regulated. Overall, they did not know further detail, including the relevant regulatory body. CONCLUSIONS: For content claims to support the consumer they need to be accurate and their use limited to healthier foods. This can be achieved by requiring products with content claims to meet NPSC thresholds, as required for products making health claims.

How healthy are Australian lunch box snacks with child-directed marketing?

ISSUE ADDRESSED: The diets of Australian children, including their lunch boxes have a disproportionate amount of discretionary foods. Packaged snacks have marketing directed to both children and parents. METHODS: Packaged school lunch box snacks were identified on supermarket websites. Nutrition information and child-directed and parent-directed marketing on the package were analysed. The "healthiness" of products was analysed using the Health Star Rating (HSR) (presently on packaging in Australia), two criteria designed for assessing food suitable for marketing to children (the Australian Health Council and the World Health Organization Western Pacific region) and Chilean criteria (used for broad food regulation). RESULTS: The average HSR of the 135 products was 2.2% and 79% had a HSR <3.5. About 39% of products had child-directed marketing. Child-directed marketing would be removed from 89% sweet snacks, and 91% savoury snacks if products with a HSR <3.5 were not allowed to carry that marketing. This is less than the proportion not allowed using criteria from Chile (100%), World Health Organization Western Pacific Region (99%) and the Australian Health Council (93%). CONCLUSIONS: A policy that disallows marketing tactics on unhealthy food based on any of the criteria studied would remove most of both child-directed and parent-directed marketing on packaged lunch box snacks. SO WHAT?: Removing child-directed marketing from unhealthy products would help parents when shopping and contribute to addressing the high proportion of discretionary foods eaten by children at school. Child-directed marketing on packaging should be a part of comprehensive regulation to protect children from the marketing of unhealthy foods.

Are physical performance and frailty assessments useful in targeting and improving access to adjuvant therapy in patients undergoing resection for pancreatic cancer?

BACKGROUND: Many patients fail to receive adjuvant chemotherapy following pancreatic cancer surgery. This study implemented a multimodal, multidisciplinary approach to improving recovery after pancreatoduodenectomy (the 'Fast Recovery' programme) and measured its impact on adjuvant chemotherapy uptake and nutritional decline. The predictive accuracies of a bundle of frailty and physical performance assessments, with respect to the recipient of adjuvant chemotherapy, were also evaluated. RESULTS: The N = 44 patients treated after the introduction of the 'Fast Recovery' programme were not found to have a significantly higher adjuvant chemotherapy uptake than the N = 409 treated before the pathway change (80.5 vs. 74.3%, p = 0.452), but did have a significantly lower average weight loss at six weeks post-operatively (mean: 4.3 vs. 6.9 kg, p = 0.013). Of the pre-operative frailty and physical performance assessments tested, the 6-min walk test was found to be the strongest predictor of the receipt of adjuvant chemotherapy (area under the ROC curve: 0.91, p = 0.001); all patients achieving distances ≥ 360 m went on to receive adjuvant chemotherapy, compared to 33% of those walking < 360 m. CONCLUSIONS: The multimodal 'Fast Recovery' programme was not found to significantly improve access to adjuvant chemotherapy, but did appear to have benefits in reducing nutritional decline. Pre-operative assessments were found to be useful in identifying patients at risk of non-receipt of adjuvant therapies, with markers of physical performance appearing to be the best predictors. As such, these markers could be useful in targeting pre- and post-habilitation measures, such as physiotherapy and improved dietetic support.

Exploring motivations for engagement with the Healthy Lunch Box campaign on social media.

Many health organisations seek social media engagement through their online health promotion campaigns, but there is little understanding of what engagement means in relation to the uptake of health messages. To understand the relevance of social media engagement, we need to look at the reasons why people engage with health content via social media. This exploratory study examined people's motivations for engaging with health content through a case study of the Healthy Lunch Box campaign. Data was collected via online focus groups (n = 7), with participants being a convenience sample of people who had seen or engaged with the Healthy Lunch Box resources (n = 24). The discussions covered reasons for engaging with the Healthy Lunch Box campaign, and more broadly with health content on social media in general. The data was analysed using a reflexive approach to thematic analysis, with themes developed inductively. The study found that some of the reasons for engagement aligned with the paradigm of social media engagement being an intermediary step in the process towards health behaviour change. However, people also described other reasons, such as alignment with their personal values, consideration of their online presentation, or as a way of curating the content they wanted to be shown on social media. These results demonstrate that people's decision to engage with health-related social media content involves more than consideration about the usefulness of the content, suggesting the need for a deeper examination of the assumptions made about the value of social media engagement in health campaign evaluations.

Chondroitin Sulphate/Dermatan Sulphate Proteoglycans: Potential Regulators of Corneal Stem/Progenitor Cell Phenotype In Vitro.

Chondroitin sulphate (CS) proteoglycans with variable sulphation-motifs along their glycosaminoglycan (GAG) chains are closely associated with the stem cell niche of articular cartilage, where they are believed to influence the characteristics of the resident stem cells. Here, we investigated the immunohistochemical distribution of hybrid CS/dermatan sulphate (DS) GAGs in the periphery of the adult chicken cornea, which is the location of the cornea's stem cell niche in a number of species, using a monoclonal antibody, 6C3, that recognises a sulphation motif-specific CS/DS GAG epitope. This revealed positive labelling that was restricted to the subepithelial corneal stroma, as well as nearby bony structures within the sclera, called ossicles. When cultivated on cell culture dishes coated with 6C3-rich CS/DS, corneal stromal cells (keratocytes) that had been isolated from embryonic chicken corneas formed circular colonies, which took several days to reach confluency. A flow cytometric analysis of these keratocytes revealed changes in their expression levels of the indicative stem cell markers, Connexin 43 (Cx43), Paired Box 6 (PAX6), B-lymphoma Moloney murine leukemia virus insertion region-1 (Bmi-1), and C-X-C Chemokine Receptor 4 (CXCR4) suggestive of a less-differentiated phenotype compared with expression levels in cells not exposed to CS/DS. These findings support the view that CS/DS promotes the retention of a stem cell phenotype in corneal cells, much as it has been proposed to do in other connective tissues.

The association of social and food preparation location context with the quality of meals and snacks consumed by young adults: findings from the MYMeals wearable camera study.

PURPOSE: This study examined the association of social contexts and food preparation location with the quality of meals and snacks (predominately from the five food groups (FFG) versus discretionary foods) in a sample of young Australian adults (18-30 years old) using wearable camera technology. METHODS: A sub-sample from the cross-sectional MYMeals study wore a wearable camera that captured images every 30 s for three consecutive days. Eating episodes from 133 participants (55% female) were classified across 4 domains: food quality (observed proportion of FFG and discretionary items), preparation location, social interaction, and screen use. Socio-economic status (SES) was assigned using residential postcode and gender self-reported. Associations of contexts and demographic factors with food quality stratified by meal type were determined using mixed binary logistic regression models. RESULTS: Of the 1840 eating episodes identified, 1775 were included in analysis (n = 8 preparation location and n = 57 food components that could not be identified were excluded). Food prepared at home was more likely to be from the FFG at lunch (OR = 4.8 95% CI 2.7-8.6), dinner (OR = 14.8 95% CI 7.6-28.6), and snacks (OR = 3.2 95% CI 2.2-4.8). Participants from higher SES areas were more likely to consume breakfasts (OR = 3.2 95% CI 1.4-7.4) and lunches (OR = 1.9 95% CI 1.0-3.7) predominately from the FFG. Females were more likely to consume lunches (OR = 2.0 95% CI 1.1-3.8) that was largely from the FFG. Social interaction and screen use were not associated with meal or snack quality. CONCLUSION: Wearable cameras have verified the importance of addressing meals and snacks prepared outside of home as an important contributor of discretionary food.

Extracellular Matrix Deposition and Remodeling after Corneal Alkali Burn in Mice.

Corneal transparency relies on the precise arrangement and orientation of collagen fibrils, made of mostly Type I and V collagen fibrils and proteoglycans (PGs). PGs are essential for correct collagen fibrillogenesis and maintaining corneal homeostasis. We investigated the spatial and temporal distribution of glycosaminoglycans (GAGs) and PGs after a chemical injury. The chemical composition of chondroitin sulfate (CS)/dermatan sulfate (DS) and heparan sulfate (HS) were characterized in mouse corneas 5 and 14 days after alkali burn (AB), and compared to uninjured corneas. The expression profile and corneal distribution of CS/DSPGs and keratan sulfate (KS) PGs were also analyzed. We found a significant overall increase in CS after AB, with an increase in sulfated forms of CS and a decrease in lesser sulfated forms of CS. Expression of the CSPGs biglycan and versican was increased after AB, while decorin expression was decreased. We also found an increase in KS expression 14 days after AB, with an increase in lumican and mimecan expression, and a decrease in keratocan expression. No significant changes in HS composition were noted after AB. Taken together, our study reveals significant changes in the composition of the extracellular matrix following a corneal chemical injury.

Changes in nutrition content and health claims post-implementation of regulation in Australia.

OBJECTIVE: To determine whether there were changes in the prevalence or healthiness of products carrying claims post-implementation of Standard 1.2.7: Nutrition, Health and Related Claims in the Australia New Zealand Food Standards Code. DESIGN: Observational survey of claims on food packages in three categories: non-alcoholic beverages, breakfast cereals and cereal bars. Nutrient profiling was applied to products to determine their eligibility to carry health claims under Standard 1.2.7. The Standard came into effect in 2013. The proportion of products carrying claims and the proportion of those not meeting the nutrient profiling criteria were calculated. A comparative analysis was conducted to determine changes between 2011 and 2016. SETTING: Three large metropolitan stores from the three major supermarket chains in Sydney, Australia were surveyed in 2011 and 2016. PARTICIPANTS: All claims on all available products in 2016 (n 1737). Nutrition composition and ingredients were collected from the packaging. RESULTS: Overall in 2016, 76 % of products carried claims and there were 7367 claims identified in the three food categories. Of products in 2016 with health claims, 34 % did not meet nutrient profiling criteria. These may breach Standard 1.2.7. Comparison of 2011-2016 showed a significant increase in the number of products carrying claims (66 v. 76 %, P < 0·001). CONCLUSIONS: The proportion of products carrying claims that do not meet nutrient profiling and consumers' tendency to infer health benefits from nutrition content claims warrants the regulation of all claims using the nutrient profiling. This will ensure consumers are not misled by claims on unhealthy food products.

Nutrient composition of Australian fast-food and fast-casual children's meals available in 2016 and changes in fast-food meals between 2010 and 2016.

OBJECTIVE: A quarter of Australian children are overweight or obese. Research conducted in 2010 found that fast-food children's meals were energy-dense and nutrient-poor. Since then, menu labelling and self-regulation of marketing have been introduced in Australia. The present study aimed to: (i) investigate the nutrient composition of children's meals offered at fast-food chains; (ii) compare these with children's daily requirements and recommendations and the food industry's own criteria for healthier children's meals; and (iii) determine whether results have changed since last investigated in 2010. DESIGN: An audit of nutrition information for fast-food children's meals was conducted. Meals were compared with 30 % (recommended contribution for a meal) and 100 % of children's daily recommendations and requirements. A comparative analysis was conducted to determine if the proportion of meals that exceeded meal requirements and recommendations, and compliance with the food industry's own criteria, changed between 2010 and 2016. SETTING: Large Australian fast-food chains. PARTICIPANTS: All possible children's meal combinations. RESULTS: Overall, 289 children's meals were included. Most exceeded 30 % of daily recommendations and requirements for a 4-year-old's energy, saturated fat, sugars and Na. Results were also substantial for 8- and 13-year-olds, particularly for Na. When compared with mean energy and nutrient contents from 2010, there were minimal changes overall. CONCLUSIONS: Children's meals can provide excess energy, saturated fat, sugar and Na to children's diets. Systematic reformulation of energy, saturated fat, sugars and Na would improve the nutrient composition of the meals.

How effective is food industry self-substantiation of food-health relationships underpinning health claims on food labels in Australia?

OBJECTIVE: The Food Standards Code regulates health claims on Australian food labels. General-level health claims highlight food-health relationships, e.g. 'contains calcium for strong bones'. Food companies making claims must notify Food Standards Australia New Zealand (FSANZ) and certify that a systematic literature review (SLR) substantiating the food-health relationship has been conducted. There is no pre- or post-notification assessment of the SLR, potentially enabling the food industry to make claims based on poor-quality research. The present study assessed the rigour of self-substantiation. DESIGN: Food-health relationships notified to FSANZ were monitored monthly between 2013 and 2017. These relationships were assessed by scoping published literature. Where evidence was equivocal/insufficient, the relevant government food regulatory agency was asked to investigate. If not investigated, or the response was unsatisfactory, the project team conducted an independent SLR which was provided to the government agency. SETTING: Australia.ParticipantsSelf-substantiated food-health relationships. RESULTS: There were sixty-seven relationships notified by thirty-eight food companies. Of these, thirty-three relationships (52 %) from twenty companies were deemed to have sufficient published evidence. Four were excluded as they originated in New Zealand. Three relationships were removed before investigations were initiated. The project initiated twenty-seven food-health relationship investigations. Another six relationships were withdrawn, and three relationships were awaiting government assessment. CONCLUSIONS: To ensure that SLR underpinning food-health relationships are rigorous and reduce regulatory enforcement burden, pre-market approval of food-health relationships should be introduced. This will increase consumer and public health confidence in the regulatory process and prevent potentially misleading general-level health claims on food labels.

Evaluation of the Cancer Council NSW Eat It To Beat It Healthy Lunch Box Sessions: A short intervention to promote the intake of fruit and vegetables among families of primary school children in NSW Australia.

ISSUE ADDRESSED: Children and adults in Australia are not eating the recommended amounts of fruits and vegetables. Our objective was to assess the effectiveness of a health promotion intervention to improve fruit and vegetable intake among primary school children and their families in NSW. METHODS: The Cancer Council New South Wales Healthy Lunch Box sessions were a 25-minute session delivered to parents of primary school-aged children. The sessions provided information and resources about fruit and vegetables and healthy school lunch boxes. The evaluation is a quantitative uncontrolled pre-post design. Data were collected using three questionnaires, pre-intervention, 1 week post-intervention and 6 months post-intervention. RESULTS: A total of 204 parents completed all three evaluation questionnaires to 6 months. Knowledge of recommended intakes and serving sizes of fruit and vegetables improved significantly after the intervention. There was an increase in parents reporting packing vegetables (often/always) in the child's lunch box at 1 week (47%) and 6 months post-intervention (40%) compared to pre-intervention (32%). The proportion of parents reporting that they were confident in packing a healthy lunch box increased from 45% pre-intervention to 62% after the intervention. CONCLUSION: The Healthy Lunch Box sessions were effective in improving parental knowledge and practices related to fruit and vegetables and parental confidence with packing a healthy lunch box. SO WHAT?: This short intervention could be a useful component of a portfolio of interventions to support parents with knowledge and resources to pack a healthy lunch box for their children.

Sustained impact of energy-dense TV and online food advertising on children's dietary intake: a within-subject, randomised, crossover, counter-balanced trial.

BACKGROUND: Policies restricting children's exposure to unhealthy food marketing have been impeded by the lack of evidence showing a direct link between food advertising exposure and children's energy intake and body weight. Food advertising exposure increases children's immediate food consumption, but whether this increased intake is compensated for at later eating occasions is not known; consequently the sustained effect on diets remains unclear. METHODS: We conducted a within-subject, randomised, crossover, counterbalanced study across four, six-day holiday camps in New South Wales, Australia between April 2016 and January 2017. Children (7-12 years, n = 160) were recruited via local schools, email networks and social media. Two gender- and age-balanced groups were formed for each camp (n = 20), randomised to either a multiple- or single- media condition and exposed to food and non-food advertising in an online game and/or a television cartoon. Children's food consumption (kilojoules) was measured at a snack immediately after exposure and then at lunch later in the day. Linear mixed models were conducted to examine relationships between food advertising exposure and dietary intake, taking into account gender, age and weight status. RESULTS: All children in the multiple-media condition ate more at a snack after exposure to food advertising compared with non-food advertising; this was not compensated for at lunch, leading to additional daily food intake of 194 kJ (95% CI 80-308, p = 0.001, d = 0.2). Exposure to multiple-media food advertising compared with a single-media source increased the effect on snack intake by a difference of 182 kJ (95% CI 46-317, p = 0.009, d = 0.4). Food advertising had an increased effect among children with heavier weight status in both media groups. CONCLUSION: Online ('advergame') advertising combined with TV advertising exerted a stronger influence on children's food consumption than TV advertising alone. The lack of compensation at lunch for children's increased snack intake after food advertising exposure suggests that unhealthy food advertising exposure contributes to a positive energy-gap, which could cumulatively lead to the development of overweight. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, number ACTRN12617001230347 (Retrospectively registered).

Monitoring the changes to the nutrient composition of fast foods following the introduction of menu labelling in New South Wales, Australia: an observational study.

OBJECTIVE: The present study examined the energy (kilojoule) content of Australian fast-food menu items over seven years, before and after introduction of menu board labelling, to determine the impact of the introduction of the legislation. DESIGN: Analysis of the median energy contents per serving and per 100g of fast-food menu items. Change in energy content of menu items across the years surveyed and differences in energy content of standard and limited-time only menu items were analysed. SETTING: Five of Australia's largest fast food chains: Hungry Jack's, KFC, McDonald's, Oporto and Red Rooster. SUBJECTS: All standard and limited-time only menu items available at each fast-food chain, collected annually for seven years, 2009-2015. RESULTS: Although some fast-food chains/menu item categories had significant increases in the energy contents of their menus at some time points during the 7-year period, overall there were no significant or systematic decreases in energy following the introduction of menu labelling (P=0·19 by +17 kJ/100 g, P=0·83 by +8 kJ/serving). Limited-time only items were significantly higher in median energy content per 100 g than standard menu items (+74 kJ/100 g, P=0·002). CONCLUSIONS: While reformulation across the entire Australian fast-food supply has the potential to positively influence population nutrient intake, the introduction of menu labelling legislation in New South Wales, Australia did not lead to reduced energy contents across the five fast-food chains. To encourage widespread reformulation by the fast-food industry and enhance the impact of labelling legislation, the government should work with industry to set targets for reformulation of nutrient content.

Children's self-regulation of eating provides no defense against television and online food marketing.

Exposure to unhealthy food marketing stimulates children's food consumption. A child's responsiveness is influenced by individual factors, resulting in an increased vulnerability to advertising effects among some children. Whether these differential responses may be altered by different parental feeding behaviours is unclear. The purpose of this study was to determine the relationship between parental feeding practices and children's food intake responses to food advertising exposure. A randomised, crossover, counterbalanced, within subject trial was conducted across four, six-day holiday camps in New South Wales, Australia between April 2016 and January 2017 with 160 children (7-12 years, n = 40/camp). Children were randomised to either a multiple media (TV and Internet) or single media (TV) condition and exposed to food (3 days) and non-food (3 days) advertising in an online game and/or a cartoon. Children's food consumption (kilojoules (kJ)) was measured at a snack immediately after advertising exposure and then at lunch later in the day. Parents completed the Child Feeding Questionnaire, and 'restriction' and 'pressure to eat' subscale scores were calculated. While food advertising affected all children in the multiple media condition, there was an increased effect on snack intake among children whose parents reported pressuring them to eat, with children consuming an additional 356 kJ after food advertising compared with non-food advertising. This was 209 kJ more than children whose parents did not pressure them to eat. In the single media condition, only children whose parents reported restrictive feeding practices ate more at lunch on food advertising days than non-food advertising days (240 kJ). These data highlight an increased susceptibility to food advertising among children whose parents report controlling feeding practices.

Tyrosine kinase inhibitors as modulators of trastuzumab-mediated antibody-dependent cell-mediated cytotoxicity in breast cancer cell lines.

BACKGROUND: Trastuzumab is an anti-HER2 monoclonal antibody (mAb) therapy capable of antibody-dependent cell-mediated cytotoxicity (ADCC) and used in the treatment of HER2+ breast cancer. Through interactions with FcÆ´R+ immune cell subsets, trastuzumab functions as a passive immunotherapy. The EGFR/HER2-targeting tyrosine kinase inhibitor (TKI) lapatinib and the next generation TKIs afatinib and neratinib, can alter HER2 levels, potentially modulating the ADCC response to trastuzumab. Using LDH-release assays, we investigated the impact of antigen modulation, assay duration and peripheral blood mononuclear cell (PBMC) activity on trastuzumab-mediated ADCC in breast cancer models of maximal (SKBR3) and minimal (MCF-7) target antigen expression to determine if modulating the ADCC response to trastuzumab using TKIs may be a viable approach for enhancing tumor immune reactivity. METHODS: HER2 levels were determined in lapatinib, afatinib and neratinib-treated SKBR3 and MCF-7 using high content analysis (HCA). Trastuzumab-mediated ADCC was assessed following treatment with TKIs utilising a colorimetric LDH release-based protocol at 4 and 12h timepoints. PBMC activity was assessed against non-MHC-restricted K562 cells. A flow cytometry-based method (CFSE/7-AAD) was also used to measure trastuzumab-mediated ADCC in medium-treated SKBR3 and MCF-7. RESULTS: HER2 antigen levels were significantly altered by the three TKIs in both cell line models. The TKIs significantly reduced LDH levels directly in SKBR3 cells but not MCF-7. Lapatinib and neratinib augment trastuzumab-related ADCC in SKBR3 but the effect was not consistent with antigen expression levels and was dependent on volunteer PBMC activity (vs. K562). A 12h assay timepoint produced more consistent results. Trastuzumab-mediated ADCC (PBMC:target cell ratio of 10:1) was measured at 7.6±4.7% (T12) by LDH assay and 19±3.2 % (T12) using the flow cytometry-based method in the antigen-low model MCF-7. CONCLUSIONS: In the presence of effector cells with high cytotoxic capacity, TKIs have the ability to augment the passive immunotherapeutic potential of trastuzumab in SKBR3, a model of HER2+ breast cancer. ADCC levels detected by LDH release assays are extremely low in MCF-7; the flow cytometry-based CFSE/7-AAD method is more sensitive and consistent for the determination of ADCC in HER2-low models.

Health and nutrition content claims on Australian fast-food websites.

OBJECTIVE: To determine the extent that Australian fast-food websites contain nutrition content and health claims, and whether these claims are compliant with the new provisions of the Australia New Zealand Food Standards Code ('the Code'). DESIGN: Systematic content analysis of all web pages to identify nutrition content and health claims. Nutrition information panels were used to determine whether products with claims met Nutrient Profiling Scoring Criteria (NPSC) and qualifying criteria, and to compare them with the Code to determine compliance. SETTING: Australian websites of forty-four fast-food chains including meals, bakery, ice cream, beverage and salad chains. SUBJECTS: Any products marketed on the websites using health or nutrition content claims. RESULTS: Of the forty-four fast-food websites, twenty (45 %) had at least one claim. A total of 2094 claims were identified on 371 products, including 1515 nutrition content (72 %) and 579 health claims (28 %). Five fast-food products with health (5 %) and 157 products with nutrition content claims (43 %) did not meet the requirements of the Code to allow them to carry such claims. CONCLUSIONS: New provisions in the Code came into effect in January 2016 after a 3-year transition. Food regulatory agencies should review fast-food websites to ensure compliance with the qualifying criteria for nutrition content and health claim regulations. This would prevent consumers from viewing unhealthy foods as healthier choices. Healthy choices could be facilitated by applying NPSC to nutrition content claims. Fast-food chains should be educated on the requirements of the Code regarding claims.

Advertising to children initiatives have not reduced unhealthy food advertising on Australian television.

Background: In response to rising childhood obesity rates, the Australian food industry implemented two initiatives in 2009 to reduce the marketing of unhealthy food to children. This study evaluated the efficacy of these initiatives on the rate of unhealthy food advertising to children on Australian television. Methods: The rates of food advertisements on three free-to-air commercial television channels and a youth-oriented digital channel in Sydney, Australia were analysed over 2 weekdays (16 h) and two weekend days (22 h). Advertisements were categorized according to the healthiness of foods advertised (non-core, core, miscellaneous) and signatory status to the food industry advertising initiatives. Results: Total food advertising rates for the three channels increased from 5.5/h in 2011 to 7.3/h in 2015, due to an increase of 0.8/h for both core and miscellaneous foods. The rate of non-core food advertisements in 2015 (3.1/h) was similar to 2011 (3.0/h). The youth-oriented channel had fewer total food advertisements (3.7/h versus 7.3/h) but similar fast-food advertisement rates (1.3/h versus 1.3/h). Conclusions: There was no change in the rate of unhealthy food advertising since 2011, suggesting minimal impact of the current food industry initiatives on reducing children's exposure to unhealthy food advertising.

Exploring perceptions and beliefs about the cost of fruit and vegetables and whether they are barriers to higher consumption.

BACKGROUND: Fruit and vegetable (F&V) consumption is below recommendations, and cost may be a barrier to meeting recommendations. Limited evidence exists on individual perceptions about the cost, actual spending and consumption of F&V. This study investigated perceptions and beliefs about cost of F&V and whether this is a barrier to higher consumption. METHODS: An online survey of Australian adults (n = 2474) measured F&V consumption; expenditure on F&V and food; and perceived barriers to consumption. Multivariable logistic regression examined associations between participants' responses about cost of F&V and demographic factors, and with actual consumption and expenditure on F&V. RESULTS: Cost was identified as a barrier for 29% of people not meeting recommended fruit servings and for 14% of people not meeting recommendations for vegetables. Cost was a more common barrier for those on lower incomes (fruit aOR 1.89; 95% CI 1.20-2.98 and vegetables aOR 2.94; 95% CI 1.97-4.39) and less common for older participants (fruit aOR 0.33; 95% CI 0.17-0.62 and vegetables aOR 0.31; 95% CI 0.18-0.52). There was no association between the perceived barriers and actual F&V spending. Twenty percent of participants said F&V were not affordable; 39% said cost made it difficult to buy F&V, and for 23% the cost of F&V meant they bought less than desired. CONCLUSIONS: A minority reported F&V were not affordable where they shopped and that cost was a barrier to higher consumption. However, it is apparent that young adults and those on low incomes eat less than they would like because of cost. Strategies that remove financial impediments to consumption are indicated for these population sub-groups.

Improving patient safety through the introduction of a formal triage process.

Emergency departments (EDs) in the UK are facing unprecedented increases in attendance, and the ability to safely assess, diagnose, treat, refer or discharge patients is a national challenge. This article discusses one component of a comprehensive ED strategy created to address serious concerns identified by regulators and develop and improve services in the department at Medway NHS Foundation Trust, Kent.

Investigating nutrient profiling and Health Star Ratings on core dairy products in Australia.

OBJECTIVE: To determine whether the ratings from the Australian front-of-pack labelling scheme, Health Star Rating (HSR), and the ability to carry health claims using the Nutrient Profiling Scoring Criterion (NPSC) for core dairy products promote foods consistent with the Australian Dietary Guidelines. DESIGN: The Australian nutrient profiling model used for assessing eligibility for health claims was compared with the nutrient profiling model underpinning the HSR system to determine their agreement when assessing dairy products. Agreement between the extent to which products met nutrient profiling criteria and scored three stars or over using the HSR calculator was determined using Cohen's kappa tests. SETTING: The four largest supermarket chains in Sydney, Australia. SUBJECTS: All available products in the milk, hard cheese, soft cheese and yoghurt categories (n 1363) were surveyed in March-May 2014. Nutrition composition and ingredients lists were recorded for each product. RESULTS: There was 'good' agreement between NPSC and HSR overall (κ=0·78; 95 % CI 0·75, 0·81; P<0·001), for hard cheeses (κ=0·72; 95 % CI 0·65, 0·79; P<0·001) and yoghurt (κ=0·79; 95 % CI 0·73, 0·86; P<0·001). There was 'fair' agreement for milk (κ=0·33; 95 % CI 0·20, 0·45; P<0·001) and 'very good' agreement for soft cheese (κ=0·84; 95 % CI 0·75, 0·92; P<0·001). Generally, products tended to have HSR consistent with other products of a similar type within their categories. CONCLUSIONS: For dairy products, the HSR scheme largely aligned with the NPSC used for determining eligibility for health claims. Both systems appeared be consistent with the Australian Dietary Guidelines for dairy products, with lower-fat products rating higher.