Greater rate of weight loss predicts paediatric hospital admission in adolescent typical and atypical anorexia nervosa.

Hospital admissions for eating disorders (ED) are rapidly increasing. Limited research exists evidencing the factors that lead to hospital admissions or their outcomes. The current study aimed to identify predictors of hospital admission in adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN). Prospective observational study including participants (n = 205) aged 11-18 and diagnosed with AN or AAN at initial ED assessment, across eight London clinics. Physical health parameters at assessment, including heart rate, blood pressure, temperature and rate of weight loss, were compared between adolescents who were admitted to a paediatric ward following assessment and those who were not admitted. The mean rate of weight loss prior to assessment was significantly higher, and mean energy intake significantly lower, in the admitted vs not admitted groups (1.2 vs 0.6kg/week, p < 0.001 and 565 kcal/day vs 857 kcal/day, p < 0.001), independent of degree of underweight. No significant differences were identified between groups in all other parameters of physical risk. Underweight adolescents with AN were equally likely to be admitted as non-underweight adolescents with AAN.  Conclusion: This study provides evidence on predictors of hospital admission, from a sample representing the London area. The assessment of weight loss speed, duration and magnitude are recommended as priority parameters that inform the risk of deterioration and the likelihood of hospital admission in adolescent AN and AAN. Further research investigating outcomes of these hospital admission is needed. What is Known: • Hospital admissions for eating disorders (ED) are rapidly increasing. • Limited research exists evidencing the factors that lead to hospital admissions, or their outcomes. What is New: • This study provides evidence on predictors of hospital admission in young people with typical and atypical anorexia nervosa. • Weight loss speed, duration, and magnitude are recommended as priority parameters that inform the risk of deterioration and the likelihood of hospital admission in this patient group.

A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa.

BACKGROUND: Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa. METHODS: The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis. RESULTS: Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium. CONCLUSIONS: Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

Grandmother presence improved grandchild survival against childhood infections but not vaccination coverage in historical Finns.

Grandmother presence can improve the number and survival of their grandchildren, but what grandmothers protect against and how they achieve it remains poorly known. Before modern medical care, infections were leading causes of childhood mortality, alleviated from the nineteenth century onwards by vaccinations, among other things. Here, we combine two individual-based datasets on the genealogy, cause-specific mortality and vaccination status of eighteenth- and nineteenth-century Finns to investigate two questions. First, we tested whether there were cause-specific benefits of grandmother presence on grandchild survival from highly lethal infections (smallpox, measles, pulmonary and diarrhoeal infections) and/or accidents. We show that grandmothers decreased all-cause mortality, an effect which was mediated through smallpox, pulmonary and diarrhoeal infections, but not via measles or accidents. Second, since grandmothers have been suggested to increase vaccination coverage, we tested whether the grandmother effect on smallpox survival was mediated through increased or earlier vaccination, but we found no evidence for such effects. Our findings that the beneficial effects of grandmothers are in part driven by increased survival from some (but not all) childhood infections, and are not mediated via vaccination, have implications for public health, societal development and human life-history evolution.

Obesity, oxidative DNA damage and vitamin D as predictors of genomic instability in children and adolescents.

BACKGROUND/OBJECTIVES: Epidemiological evidence indicates obesity in childhood and adolescence to be an independent risk factor for cancer and premature mortality in adulthood. Pathological implications from excess adiposity may begin early in life. Obesity is concurrent with a state of chronic inflammation, a well-known aetiological factor for DNA damage. In addition, obesity has been associated with micro-nutritional deficiencies. Vitamin D has attracted attention for its anti-inflammatory properties and role in genomic integrity and stability. The aim of this study was to determine a novel approach for predicting genomic instability via the combined assessment of adiposity, DNA damage, systemic inflammation, and vitamin D status. SUBJECTS/METHODS: We carried out a cross-sectional study with 132 participants, aged 10-18, recruited from schools and paediatric obesity clinics in London. Anthropometric assessments included BMI Z-score, waist and hip circumference, and body fat percentage via bioelectrical impedance. Inflammation and vitamin D levels in saliva were assessed by enzyme-linked immunosorbent assay. Oxidative DNA damage was determined via quantification of 8-hydroxy-2'-deoxyguanosine in urine. Exfoliated cells from the oral cavity were scored for genomic instability via the buccal cytome assay. RESULTS: As expected, comparisons between participants with obesity and normal range BMI showed significant differences in anthropometric measures (p < 0.001). Significant differences were also observed in some measures of genomic instability (p < 0.001). When examining relationships between variables for all participants, markers of adiposity positively correlated with acquired oxidative DNA damage (p < 0.01) and genomic instability (p < 0.001), and negatively correlated with vitamin D (p < 0.01). Multiple regression analyses identified obesity (p < 0.001), vitamin D (p < 0.001), and oxidative DNA damage (p < 0.05) as the three significant predictors of genomic instability. CONCLUSIONS: Obesity, oxidative DNA damage, and vitamin D deficiency are significant predictors of genomic instability. Non-invasive biomonitoring and predictive modelling of genomic instability in young patients with obesity may contribute to the prioritisation and severity of clinical intervention measures.

Maternal age at birth shapes offspring life-history trajectory across generations in long-lived Asian elephants.

Advanced maternal age at birth can have pronounced consequences for offspring health, survival and reproduction. If carried over to the next generation, such fitness effects could have important implications for population dynamics and the evolution of ageing, but these remain poorly understood. While many laboratory studies have investigated maternal age effects, relatively few studies have been conducted in natural populations, and they usually only present a "snapshot" of an offspring's lifetime. In the present study, we focus on how maternal age influences offspring life-history trajectories and performance in a long-lived mammal. We use a multigenerational demographic dataset of semi-captive Asian elephants to investigate maternal age effects on several offspring life-history traits: condition, reproductive success and overall survival. We show that offspring born to older mothers display reduced overall survival but higher reproductive success, and reduced survival of their own progeny. Our results show evidence of a persistent effect of maternal age on fitness across generations in a long-lived mammal. By highlighting transgenerational effects on the fitness of the next generation associated with maternal age, the present study helps increase our understanding of factors contributing to individual variation in ageing rates and fitness.

Asian elephants exhibit post-reproductive lifespans.

BACKGROUND: The existence of extended post-reproductive lifespan is an evolutionary puzzle, and its taxonomic prevalence is debated. One way of measuring post-reproductive life is with post-reproductive representation, the proportion of adult years lived by females after cessation of reproduction. Analyses of post-reproductive representation in mammals have claimed that only humans and some toothed whale species exhibit extended post-reproductive life, but there are suggestions of a post-reproductive stage for false killer whales and Asian elephants. Here, we investigate the presence of post-reproductive lifespan in Asian elephants using an extended demographic dataset collected from semi-captive timber elephants in Myanmar. Furthermore, we investigate the sensitivity of post-reproductive representation values to availability of long-term data over 50 years. RESULTS: We find support for the presence of an extended post-reproductive stage in Asian elephants, and that post-reproductive representation and its underlying demographic rates depend on the length of study period in a long-lived animal. CONCLUSIONS: The extended post-reproductive lifespan is unlikely due to physiological reproductive cessation, and may instead be driven by mating preferences or condition-dependent fertility. Our results also show that it is crucial to revisit such population measures in long-lived species as more data is collected, and if the typical lifespan of the species exceeds the initial study period.

Limited support for the X-linked grandmother hypothesis in pre-industrial Finland.

The level of kin help often depends on the degree of relatedness between a helper and the helped. In humans, grandmother help is known to increase the survival of grandchildren, though this benefit can differ between maternal grandmothers (MGMs) and paternal grandmothers (PGMs) and between grandsons and granddaughters. The X-linked grandmother hypothesis posits that differential X-chromosome relatedness between grandmothers and their grandchildren is a leading driver of differential grandchild survival between grandmother lineages and grandchild sexes. We tested this hypothesis using time-event models on a large, multigenerational dataset from pre-industrial Finland. We found that the presence of an MGM increases grandson survival more than PGM presence, and that granddaughter survival is higher than that of grandsons in the presence of a PGM. However, there was no support for the key prediction that the presence of PGMs improves granddaughter survival more than that of MGMs, diminishing the overall support for the hypothesis. Our results call for alternative explanations for differences in the effects of maternal and paternal kin to grandchild survival in humans.

Revealing the complexity of quitting smoking: a qualitative grounded theory study of the natural history of quitting in Australian ex-smokers.

OBJECTIVE: To explore the quitting histories of Australian ex-smokers in order to develop an understanding of the varied contribution of smoking cessation assistance (either pharmacotherapy or professionally mediated behavioural support) to the process of quitting. DESIGN: Qualitative grounded theory study; in-depth interviews. PARTICIPANTS: 37 Australian adult ex-smokers (24-68 years; 15 men, 22 women) who quit in the past 6-24 months. RESULTS: Although participants' individual quitting histories and their overall experiences of quitting were unique, when the 37 quitting histories were compared it was clear two experiences were common to almost all participants: almost no one quit at their first quit attempt and almost everyone started out quitting unassisted. Furthermore, distinct patterns existed in the timing and use of assistance, in particular the age at which assistance was first used, how some participants were resolutely uninterested in assistance, and how assistance might have contributed to the process of successful quitting even if not used on the final quit attempt. Importantly, three patterns in use of assistance were identified: (1) only ever tried to quit unassisted (n=13); (2) started unassisted, tried assistance but reverted back to unassisted (n=13); (3) started unassisted, tried assistance and quit with assistance (n=11). For most participants, insight into what quitting would require was only gained through prior quitting experiences with and without assistance. For a number of participants, interest in assistance was at its lowest when the participant was most ready to quit. CONCLUSION: Quitting should be viewed as a process drawing on elements of assisted and unassisted quitting rather than a stand-alone event that can be labelled as strictly assisted or unassisted.

Measured, opportunistic, unexpected and naïve quitting: a qualitative grounded theory study of the process of quitting from the ex-smokers' perspective.

BACKGROUND: To better understand the process of quitting from the ex-smokers' perspective, and to explore the role spontaneity and planning play in quitting. METHODS: Qualitative grounded theory study using in-depth interviews with 37 Australian adult ex-smokers (24-68 years; 15 males, 22 females) who quit smoking in the past 6-24 months (26 quit unassisted; 11 used assistance). RESULTS: Based on participants' accounts of quitting, we propose a typology of quitting experiences: measured, opportunistic, unexpected and naïve. Two key features integral to participants' accounts of their quitting experiences were used as the basis of the typology: (1) the apparent onset of quitting (gradual through to sudden); and (2) the degree to which the smoker appeared to have prepared for quitting (no evidence through to clear evidence of preparation). The resulting 2 × 2 matrix of quitting experiences took into consideration three additional characteristics: (1) the presence or absence of a clearly identifiable trigger; (2) the amount of effort (cognitive and practical) involved in quitting; and (3) the type of cognitive process that characterised the quitting experience (reflective; impulsive; reflective and impulsive). CONCLUSIONS: Quitting typically included elements of spontaneity (impulsive behaviour) and preparation (reflective behaviour), and, importantly, the investment of time and cognitive effort by participants prior to quitting. Remarkably few participants quit completely out-of-the-blue with little or no preparation. Findings are discussed in relation to stages-of-change theory, catastrophe theory, and dual process theories, focusing on how dual process theories may provide a way of conceptualising how quitting can include elements of both spontaneity and preparation.

Association Between Gun Law Reforms and Intentional Firearm Deaths in Australia, 1979-2013.

IMPORTANCE: Rapid-fire weapons are often used by perpetrators in mass shooting incidents. In 1996 Australia introduced major gun law reforms that included a ban on semiautomatic rifles and pump-action shotguns and rifles and also initiated a program for buyback of firearms. OBJECTIVE: To determine whether enactment of the 1996 gun laws and buyback program were followed by changes in the incidence of mass firearm homicides and total firearm deaths. DESIGN: Observational study using Australian government statistics on deaths caused by firearms (1979-2013) and news reports of mass shootings in Australia (1979-May 2016). Changes in intentional firearm death rates were analyzed with negative binomial regression, and data on firearm-related mass killings were compared. EXPOSURES: Implementation of major national gun law reforms. MAIN OUTCOMES AND MEASURES: Changes in mass fatal shooting incidents (defined as ≥5 victims, not including the perpetrator) and in trends of rates of total firearm deaths, firearm homicides and suicides, and total homicides and suicides per 100,000 population. RESULTS: From 1979-1996 (before gun law reforms), 13 fatal mass shootings occurred in Australia, whereas from 1997 through May 2016 (after gun law reforms), no fatal mass shootings occurred. There was also significant change in the preexisting downward trends for rates of total firearm deaths prior to vs after gun law reform. From 1979-1996, the mean rate of total firearm deaths was 3.6 (95% CI, 3.3-3.9) per 100,000 population (average decline of 3% per year; annual trend, 0.970; 95% CI, 0.963-0.976), whereas from 1997-2013 (after gun law reforms), the mean rate of total firearm deaths was 1.2 (95% CI, 1.0-1.4) per 100,000 population (average decline of 4.9% per year; annual trend, 0.951; 95% CI, 0.940-0.962), with a ratio of trends in annual death rates of 0.981 (95% CI, 0.968-0.993). There was a statistically significant acceleration in the preexisting downward trend for firearm suicide (ratio of trends, 0.981; 95% CI, 0.970-0.993), but this was not statistically significant for firearm homicide (ratio of trends, 0.975; 95% CI, 0.949-1.001). From 1979-1996, the mean annual rate of total nonfirearm suicide and homicide deaths was 10.6 (95% CI, 10.0-11.2) per 100,000 population (average increase of 2.1% per year; annual trend, 1.021; 95% CI, 1.016-1.026), whereas from 1997-2013, the mean annual rate was 11.8 (95% CI, 11.3-12.3) per 100,000 (average decline of 1.4% per year; annual trend, 0.986; 95% CI, 0.980-0.993), with a ratio of trends of 0.966 (95% CI, 0.958-0.973). There was no evidence of substitution of other lethal methods for suicides or homicides. CONCLUSIONS AND RELEVANCE: Following enactment of gun law reforms in Australia in 1996, there were no mass firearm killings through May 2016. There was a more rapid decline in firearm deaths between 1997 and 2013 compared with before 1997 but also a decline in total nonfirearm suicide and homicide deaths of a greater magnitude. Because of this, it is not possible to determine whether the change in firearm deaths can be attributed to the gun law reforms.

Distinguishing between determinate and indeterminate growth in a long-lived mammal.

BACKGROUND: The growth strategy of a species influences many key aspects of its life-history. Animals can either grow indeterminately (throughout life), or grow determinately, ceasing at maturity. In mammals, continued weight gain after maturity is clearly distinguishable from continued skeletal growth (indeterminate growth). Elephants represent an interesting candidate for studying growth because of their large size, long life and sexual dimorphism. Objective measures of their weight, height and age, however, are rare. RESULTS: We investigate evidence for indeterminate growth in the Asian elephant Elephas maximus using a longitudinal dataset from a semi-captive population. We fit growth curves to weight and height measurements, assess sex differences in growth, and test for indeterminate growth by comparing the asymptotes for height and weight curves. Our results show no evidence for indeterminate growth in the Asian elephant; neither sex increases in height throughout life, with the majority of height growth completed by the age of 15 years in females and 21 years in males. Females show a similar pattern with weight, whereas males continue to gain weight until over age 50. Neither sex shows any declines in weight with age. CONCLUSIONS: These results have implications for understanding mammalian life-history, which could include sex-specific differences in trade-offs between size and reproductive investment.

Tracking funded health intervention research.

OBJECTIVE: To describe the research publication outputs from intervention research funded by Australia's National Health and Medical Research Council (NHMRC). DESIGN AND SETTING: Analysis of descriptive data and data on publication outputs collected between 23 July 2012 and 10 December 2013 relating to health intervention research project grants funded between 1 January 2003 and 31 December 2007. MAIN OUTCOME MEASURES: Stages of development of intervention studies (efficacy, effectiveness, replication, adaptation or dissemination of intervention); types of interventions studied; publication output per NHMRC grant; and whether interventions produced statistically significant changes in primary outcome variables. RESULTS: Most of the identified studies tested intervention efficacy or effectiveness in clinical or community settings, with few testing the later stages of intervention development, such as replication, adaptation or dissemination. Studies focused largely on chronic disease treatment and management, and encompassed various medical and allied health disciplines. Equal numbers of studies had interventions that produced statistically significant results on primary outcomes, (27) and those that did not (27). The mean number of total published articles per grant was 3.3, with 2.0 articles per grant focusing on results, and the remainder covering descriptive, exploratory or methodological aspects of intervention research. CONCLUSIONS: Our study provides a benchmark for the publication outputs of NHMRC-funded health intervention research in Australia. Research productivity is particularly important for intervention research, where findings are likely to have more immediate and direct applicability to health policy and practice. Tracking research outputs in this way provides information on whether current research investment patterns match the need for evidence about health care interventions.

Disadvantaged youth and smoking in mature tobacco control contexts: a systematic review and synthesis of qualitative research.

OBJECTIVE: To review qualitative research and synthesise findings about socioeconomically disadvantaged and socially marginalised adolescents and young adults in mature tobacco control contexts. DATA SOURCES: Searches of PubMed and MEDLINE, additional purposive searches in Google Scholar, PsycINFO, grey literature, specialist journals and reference lists for English language articles published after 2000. Search terms were qualitative, youth or adolescent or young adult, smoking/tobacco and vulnerable populations or disadvantage or socioeconomic inequality. The most recent update of the search was undertaken in January 2014. STUDY SELECTION: Twenty articles, reporting on 17 studies, from 902 initial records were included. Inclusion criteria were: qualitative study undertaken in a country in the final stage of the tobacco epidemic and with comprehensive tobacco control measures in place, participants were youth who were socioeconomically disadvantaged or members of an identified subgroup with higher smoking prevalence and/or resided in a geographical area of low socioeconomic status. The target age range was 10-24. DATA EXTRACTION: Data were independently extracted by one author, summarised and reviewed, compared and re-reviewed at multiple time points. DATA SYNTHESIS: The majority of studies were from the UK, with the remainder from the USA, Australia and New Zealand. The review used a thematic analysis approach, and started with an open question: 'what does qualitative research tell us about disadvantaged young people and smoking?' The synthesis provides insights into the social context of smoking for marginalised and disadvantaged young people, group affiliation and identity, the role of smoking in social capital and sources of cigarettes. CONCLUSIONS: Surprisingly few qualitative studies focused exclusively on smoking and disadvantaged young people were found. Future qualitative studies on the intersection between specific psychosocial characteristics associated with disadvantage and increased smoking risk would be of use to inform approaches to reduce socioeconomic differentials in smoking prevalence.

What do we know about unassisted smoking cessation in Australia? A systematic review, 2005-2012.

CONTEXT: A significant proportion of smokers who quit do so on their own without formal help (ie, without professionally or pharmacologically mediated assistance), yet research into how smokers quit focuses primarily on assisted methods of cessation. OBJECTIVE: The aim of the present work was to systematically review recent smoking cessation research in Australia, a nation advanced in tobacco control, to determine what is known about smokers who quit unassisted in order to (1) inform a research agenda to develop greater understanding of the many smokers who quit unassisted and (2) elucidate possible lessons for policy and mass communication about cessation. METHODS: In January 2013, four e-databases and the grey literature were searched for articles published between 2005 and 2012 on smoking cessation in Australia. Articles focusing solely on interventions designed to stimulate cessation were excluded, as were articles focusing solely on assisted cessation, leaving articles reporting on smokers who quit unassisted. Data from articles reporting on unassisted cessation were extracted and grouped into related categories. RESULTS: A total of 248 articles reported on smoking cessation, of which 63 focused solely on interventions designed to stimulate cessation, leaving 185 reporting on the method of cessation ('how' a smoker quits). Of these, 166 focused solely on assisted cessation, leaving 19 reporting, either directly or indirectly, on smokers who quit unassisted. Data from these studies indicated 54% to 69% of ex-smokers quit unassisted and 41% to 58% of current smokers had attempted to quit unassisted. CONCLUSIONS: The majority of Australian smokers quit or attempt to quit unassisted, yet little research has been dedicated to understanding this process. Almost all research that reported unassisted cessation referenced it as a comparator to the focal point of assisted cessation. Public health may benefit from insights gained from greater research into the cessation method used by most smokers. Suggestions and a rationale for such research are provided.

Does health intervention research have real world policy and practice impacts: testing a new impact assessment tool.

BACKGROUND: There is a growing emphasis on the importance of research having demonstrable public benefit. Measurements of the impacts of research are therefore needed. We applied a modified impact assessment process that builds on best practice to 5 years (2003-2007) of intervention research funded by Australia's National Health and Medical Research Council to determine if these studies had post-research real-world policy and practice impacts. METHODS: We used a mixed method sequential methodology whereby chief investigators of eligible intervention studies who completed two surveys and an interview were included in our final sample (n = 50), on which we conducted post-research impact assessments. Data from the surveys and interviews were triangulated with additional information obtained from documentary analysis to develop comprehensive case studies. These case studies were then summarized and the reported impacts were scored by an expert panel using criteria for four impact dimensions: corroboration; attribution, reach, and importance. RESULTS: Nineteen (38%) of the cases in our final sample were found to have had policy and practice impacts, with an even distribution of high, medium, and low impact scores. While the tool facilitated a rigorous and explicit criterion-based assessment of post-research impacts, it was not always possible to obtain evidence using documentary analysis to corroborate the impacts reported in chief investigator interviews. CONCLUSIONS: While policy and practice is ideally informed by reviews of evidence, some intervention research can and does have real world impacts that can be attributed to single studies. We recommend impact assessments apply explicit criteria to consider the corroboration, attribution, reach, and importance of reported impacts on policy and practice. Impact assessments should also allow sufficient time between impact data collection and completion of the original research and include mechanisms to obtain end-user input to corroborate claims and reduce biases that result from seeking information from researchers only.

Digital junk: food and beverage marketing on Facebook.

OBJECTIVES: We assessed the amount, reach, and nature of energy-dense, nutrient-poor (EDNP) food and beverage marketing on Facebook. METHODS: We conducted a content analysis of the marketing techniques used by the 27 most popular food and beverage brand Facebook pages in Australia. We coded content across 19 marketing categories; data were collected from the day each page launched (mean = 3.65 years of activity per page). RESULTS: We analyzed 13 international pages and 14 Australian-based brand pages; 4 brands (Subway, Coca-Cola, Slurpee, Maltesers) had both national and international pages. Pages widely used marketing features unique to social media that increase consumer interaction and engagement. Common techniques were competitions based on user-generated content, interactive games, and apps. Four pages included apps that allowed followers to place an order directly through Facebook. Adolescent and young adult Facebook users appeared most receptive to engaging with this content. CONCLUSIONS: By using the interactive and social aspects of Facebook to market products, EDNP food brands capitalize on users' social networks and magnify the reach and personal relevance of their marketing messages.

Drop the Salt! Assessing the impact of a public health advocacy strategy on Australian government policy on salt.

OBJECTIVE: In 2007 the Australian Division of World Action on Salt and Health (AWASH) launched a campaign to encourage the Australian government to take action to reduce population salt intake. The objective of the present research was to assess the impact of the Drop the Salt! campaign on government policy. DESIGN: A review of government activities related to salt reduction was conducted and an advocacy strategy implemented to increase government action on salt. Advocacy actions were documented and the resulting outcomes identified. An analysis of stakeholder views on the effectiveness of the advocacy strategy was also undertaken. Settings Advocacy activities were coordinated through AWASH at the George Institute for Global Health in Sydney. SUBJECTS: All relevant State and Federal government statements and actions were reviewed and thirteen stakeholders with known interests or responsibilities regarding dietary salt, including food industry, government and health organisations, were interviewed. RESULTS: Stakeholder analysis affirmed that AWASH influenced the government's agenda on salt reduction and four key outputs were attributed to the campaign: (i) the Food Regulation Standing Committee discussions on salt, (ii) the Food and Health Dialogue salt targets, (iii) National Health and Medical Research Council partnership funding and (iv) the New South Wales Premier's Forum on Fast Foods. CONCLUSIONS: While it is not possible to definitively attribute changes in government policy to one organisation, stakeholder research indicated that the AWASH campaign increased the priority of salt reduction on the government's agenda. However, a coordinated government strategy on salt reduction is still required to ensure that the potential health benefits are fully realised.