Factors influencing fruit and vegetable intake among urban Fijians: A qualitative study.

Low fruit and vegetable intake is an important risk factor for micronutrient deficiencies and non-communicable diseases, but many people worldwide, including most Fijians, eat less than the World Health Organization recommended amount. The present qualitative study explores factors that influence fruit and vegetable intake among 57 urban Fijians (50 women, 7 men) of indigenous Fijian (iTaukei) and South Asian (Indian) descent. Eight focus group discussions were held in and around Suva, Fiji's capital and largest urban area, which explored motivation for eating fruit and vegetables, understandings of links to health and disease, availability and sources, determinants of product choice, and preferred ways of preparing and eating fruit and vegetables. Data were analysed using thematic content analysis. Regardless of ethnicity, participants indicated that they enjoyed and valued eating fruit and vegetables, were aware of the health benefits, and had confidence in their cooking skills. In both cultures, fruit and vegetables were essential components of traditional diets. However, increasing preferences for processed and imported foods, and inconsistent availability and affordability of high-quality, low-priced, fresh produce, were identified as important barriers. The findings indicate that efforts to improve fruit and vegetable intake in urban Fijians should target the stability of the domestic fruit and vegetable supply and access.

Prioritizing policy interventions to improve diets? Will it work, can it happen, will it do harm?

Policies from non-health sectors have considerable impacts on the food environment and in turn on population nutrition. Health impact assessment (HIA) methods have been developed to identify the potential health effects of non-health policies; however, they are underused both within and outside the health sector. HIA and other assessment methods and tools can be used more extensively in health promotion to assist with the identification of the best policy options to pursue to improve and protect health. A participatory process is presented in this paper which combines HIAs with feasibility and effectiveness assessments. The intention is to enable health promoters to more accurately identify which policy change options would be most likely to improve diets, considering both impact and likelihood of implementation. The process was successfully used in Fiji and Tonga and provided a more systematic way of understanding which policy interventions showed the most promise.

Developmental disorders of the fetus in some arthropod-borne virus infections.

A number of arboviruses have been associated with congenital defects in domestic aminals and man. In this review comparison is made of the temporal association between epidemics of arboviruses affecting man and animals in which there is an obvious relationship between the infection and the fetal defects, and arboviruses which cause no overt clinical symptoms in the vertebrate host but result in deformities of the fetus. The danger to the fetus following the use of live attenuated virus vaccines against several important arbovirus diseases is also examined. It is concluded that arboviruses which are capable of infecting humans or animals without producing overt clinical signs, and attenuated vaccine viruses pose the greatest threat to the fetus.

Serological studies of Australian and Papua New Guinean cattle and Australian sheep for the presence of antibodies against bluetongue group viruses.

Following isolation of a virus (CSIRO19) from insects in Australia and its identification as bluetongue virus serotype 20 (BTV20), a nationwide survey of antibodies in cattle and sheep sera was undertaken. Initial studies using the serum neutralization (SN) test showed that the distribution of BTV20 antibodies in cattle was confined to the northern part of Australia. Group-reactive antibody tests (agar gel diffusion precipitin, AGDP, and complement-fixation, CF) showed group-reactive cattle sera south of the BTV20 zone (northern Australia), and southwards from Queensland to New South Wales. Very few group-reactive sheep sera (45 out of 16213) were found and these were of doubtful epidemiological significance. Some of these BTV group-reactive, BTV20-negative, sera were tested in SN tests against BTV1 to 17 and Ibaraki (IBA) virus. The results indicated that BTV1, or a closely related orbivirus, was active in cattle in Queensland, northern Western Australia, and New South Wales, and that antibody to BTV15 was present in some of the cattle sera in northern Western Australia and the Northern Territory. Antibody to IBA virus was present in some cattle sera in Queensland, northern Western Australia and New South Wales. SN antibody titres greater than or equal to 60 were also found to a number of other BTV serotypes in cattle sera in northern Western Australia and Queensland (principally, BTV2 and BTV7). Low level reactions were commonly observed against these and a number of other BTV serotypes, often in the same serum samples. Further, 22% of the group-reactive cattle sera did not react with any of the viruses in the SN tests. Such results were difficult to interpret in terms of known Australian BTV or BTV-related isolates.

Experimental infection of bulls with Akabane virus.

Eight bulls were inoculated with Akabane virus and the clinical effects, development of viraemia and serological response to infection were followed. In addition semen was collected regularly from each bull both before and after inoculation. The bulls had a viraemia which occurred between days 2 and 9 after inoculation and which lasted for three to five days. Virus neutralising antibodies were detected in the serum of all bulls by days 7 to 10. Semen samples were tested for virus by inoculation of tissue cultures and by subcutaneous injection of susceptible cattle. Akabane virus was not detected in the semen using either method. The semen was usually of a standard acceptable for artificial breeding. The results of this study suggest that Akabane virus infection of the bull would not affect reproduction.

The effect of natural and artificial breeding using bulls infected with, or semen contaminated with, infectious bovine rhinotracheitis virus.

Ten cows and heifers (Group B) were inoculated into the uterus at oestrus with semen followed by IBR virus for the first insemination and semen alone if a second insemination was necessary. All animals developed infectious pustular vulvo-vaginitis (IPV), and 2 cows conceived to the first and 2 to the second insemination (pregnancy rate of 40 percent requiring 4.5 services per conception). This group was compared with 10 control animals (Group A) which were treated similarly but received tissue culture fluid instead of virus at the first insemination. Group A had a pregnancy rate of 90 percent requiring 1.7 services per conception. Natural mating of 4 bulls with preputial infections due to infectious bovine rhinotracheitis (IBR) virus with 9 susceptible cows and heifers (group D), resulted in the production of lesions of IPV. The IPV infection did not affect their fertility (pregnancy rate of 89 percent requiring 1.4 services per conception) when it was compared to a similar group of females (group C) mated to the same bulls prior to infection with IBR virus (pregnancy rate of 100 percent requiring 1.2 services per conception). The 6 animals in Group B that were not pregnant and returned to oestrus 3 times were found on slaughter to have endometritis, salpingitis and vaginitis. A high incidence, 5 out of 18 (28 percent), of shortened oestrous cycles (less than 18 days) was a feature of the breeding pattern of this group. The undesirable consequences of distributing semen contaminated with IBR virus from artificial insemination centres are apparent.

The role of wild animals in the spread of exotic diseases in Australia.

The distributions of the following feral animals are given -- cattle, buffalo, pig, goat, deer, camel, horse, donkey, fox, dog and cat -- and the native dingo. The possible role these and the native rodents, marsupials and monotremes would play should an exotic disease of livestock enter Australia is discussed. It is considered that feral animals would be important in creating foci from which the disease would spread.

Sugar-sweetened beverages in Pacific Island countries and territories: problems and solutions?

Non-communicable diseases are a major problem in the Pacific Islands, with poor diets an important contributing factor. Available data suggests high levels of intake of sugar-sweetened beverages (SSBs) across the region, and particularly in adolescents. Due to concerns about the risks to health of high intakes, efforts have been made across the region to reduce the intake of SSBs. French Polynesia, Nauru, Cook Islands, Tonga and Fiji have implemented sales or excise taxes on SSBs to increase the price to the consumer. Many countries in the region have adopted school food policies which intend to limit or ban access to SSBs in schools. Guam also adopted legislation to ensure that healthier foods and beverages were available in all vending machines in schools. Efforts to control advertising and sponsorship of SSBs have been limited to-date in the region, although some school food policies do restrict advertising and sponsorship in schools, school grounds and school vehicles. Efforts around education and awareness raising have shown mixed success in terms of changing behaviour. Greater attention is needed to evaluate the impact of these measures to ensure that actions are effective, and to increase the evidence regionally of the most effective approaches to tackle SSBs.

Descriptive analysis of diabetes-related amputations at the Colonial War Memorial Hospital, Fiji, 2010-2012.

SETTING: The Colonial War Memorial Hospital (CWMH) in Fiji. OBJECTIVE: To determine the characteristics of patients with diabetes mellitus (DM) who underwent lower limb amputations at the CWMH from 2010 to 2012. DESIGN: This was a retrospective review of data contained in operating theatre registers and clinical records of DM patients who had undergone amputations during the study period. RESULT: Of the 938 amputations performed at the CWMH during the study period, significantly more patients were male than female (54.1% vs. 45.9%) and more i-Taukei (indigenous Fijian) than Indo-Fijian (71% vs. 26.2%); 15.9% of patients had not previously been diagnosed as having DM when they presented with foot sepsis. The rate of smoking was highest in male i-Taukei patients. A large proportion of patients (76.8%) had poor glycaemic control. CONCLUSION: This study suggests that male i-Taukeis are most at risk, and that uncontrolled DM is a significant factor associated with amputations. There is a need to strengthen DM screening and improve glycaemic control. Foot care education needs to be implemented at diagnosis and re-enforced with regular clinic visits and complication screening sessions.

Contexte : L'hôpital Colonial War Memorial (CWMH) aux Fidji.Contexte : Déterminer les caractéristiques des patients avec diabète (DM) qui ont subi une amputation du membre inférieur à CWMH entre 2010 et 2012.Schéma : Revue rétrospective des données des registres du bloc opératoire et des dossiers cliniques des patients avec DM qui ont subi une amputation du membre inférieur pendant cette période.Résultats : Au total, 938 amputations ont été pratiquées à CWMH pendant la période d'étude. Les hommes étaient significativement plus nombreux (54,1%) que les femmes (45,9%) et plus souvent d'ethnie i-Taukei (indigène) (71%) comparés aux patients Indo- Fidjiens (26,2%) ; 15,9% des patients n'avaient pas eu de diagnostic de DM quand ils sont arrivés avec une infection du pied. Le taux de fumeurs était le plus élevé chez les patients masculins i-Taukei. Une grande proportion des patients (76,8%) contrôlait mal sa glycémie.Conclusion : Cette étude suggère que les hommes i-Taukei sont le groupe le plus à risque et qu'un DM mal contrôlé est un facteur significativement associé à une amputation. Il est donc nécessaire de renforcer le dépistage du DM et d'améliorer le contrôle de la glycémie. Les patients doivent apprendre à prendre soin de leurs pieds dès le diagnostic et lors de consultations régulières par la suite, notamment de séances de dépistage des complications.

Marco de referencia: El hospital Colonial War Memorial (CMWH) de Fiji.Objetivo: Definir las características de los pacientes con diabetes (DM), en quienes se practicó una amputación de miembros inferiores en el CMWH del 2010 al 2012.Método: Fue este un análisis retrospectivo de los registros de los quirófanos y las historias clínicas de los pacientes con DM en quienes se practicó una amputación durante el período del estudio.Resultado: En CMWH se llevaron a cabo 938 amputaciones durante el período estudiado. Hubo una mayoría significativa de pacientes de sexo masculino (54,1%) en comparación con la proporción de mujeres (45,9%) y de i-Taukei (fiyianos autóctonos; 71%) en comparación con fiyianos de origen indio (26,2%). En el 15,9% de los pacientes no se había establecido el diagnóstico de DM antes de su consulta por sepsis del pie. La tasa más alta de fumadores se observó en los pacientes i-Taukei de sexo masculino. En gran número de pacientes la regulación de la glucemia era deficiente (76,8%).Conclusión: Los resultados del estudio indican que el grupo con mayor riesgo de presentar una DM mal regulada son los i-Taukei de sexo masculino y la DM desestabilizada constituye un factor importante asociado con las amputaciones. Es urgente fortalecer la detección sistemática de la DM y mejorar la regulación de la glucemia. Se precisa impartir a los pacientes una educación en materia de cuidado de los pies cuando se establece el diagnóstico de DM y reforzarla en las consultas periódicas y en las sesiones de detección de complicaciones.

Trade policy and obesity prevention: challenges and innovation in the Pacific Islands.

The Pacific Island countries experience some of the highest rates of obesity in the world in part due to substantial dietary changes that mirror changes in the food supply in the region. Economic and political ties, donor aid, and trade links are key drivers of the changing availability and accessibility of processed and imported foods. Pacific Island countries have been innovative in developing trade-related policy approaches to create a less obesogenic food environment. Taxation-based approaches that affect pricing in the region include increased import and excise tariffs on sugared beverages and other high-sugar products, monosodium glutamate, and palm oil and lowered tariffs on fruits and vegetables. Other approaches highlight some higher-fat products through labeling and controlling the supply of high-fat meats. The bans on high-fat turkey tails and mutton flaps highlight the politics, trade agreements and donor influences that can be significant barriers to the pursuit of policy options. Countries that are not signatories to trade agreements may have more policy space for innovative action. However, potential effectiveness and practicality require consideration. The health sector's active engagement in the negotiation of trade agreements is a key way to support healthier trade in the region.

Monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in community and consumer retail food environments globally.

Retail food environments are increasingly considered influential in determining dietary behaviours and health outcomes. We reviewed the available evidence on associations between community (type, availability and accessibility of food outlets) and consumer (product availability, prices, promotions and nutritional quality within stores) food environments and dietary outcomes in order to develop an evidence-based framework for monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in retail food environments. Current evidence is suggestive of an association between community and consumer food environments and dietary outcomes; however, substantial heterogeneity in study designs, methods and measurement tools makes it difficult to draw firm conclusions. The use of standardized tools to monitor local food environments within and across countries may help to validate this relationship. We propose a step-wise framework to monitor and benchmark community and consumer retail food environments that can be used to assess density of healthy and unhealthy food outlets; measure proximity of healthy and unhealthy food outlets to homes/schools; evaluate availability of healthy and unhealthy foods in-store; compare food environments over time and between regions and countries; evaluate compliance with local policies, guidelines or voluntary codes of practice; and determine the impact of changes to retail food environments on health outcomes, such as obesity.

Monitoring and benchmarking population diet quality globally: a step-wise approach.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support) aims to monitor and benchmark the healthiness of food environments globally. In order to assess the impact of food environments on population diets, it is necessary to monitor population diet quality between countries and over time. This paper reviews existing data sources suitable for monitoring population diet quality, and assesses their strengths and limitations. A step-wise framework is then proposed for monitoring population diet quality. Food balance sheets (FBaS), household budget and expenditure surveys (HBES) and food intake surveys are all suitable methods for assessing population diet quality. In the proposed 'minimal' approach, national trends of food and energy availability can be explored using FBaS. In the 'expanded' and 'optimal' approaches, the dietary share of ultra-processed products is measured as an indicator of energy-dense, nutrient-poor diets using HBES and food intake surveys, respectively. In addition, it is proposed that pre-defined diet quality indices are used to score diets, and some of those have been designed for application within all three monitoring approaches. However, in order to enhance the value of global efforts to monitor diet quality, data collection methods and diet quality indicators need further development work.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles.

Non-communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public-interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two 'process' modules, that monitor the policies and actions of the public and private sectors, seven 'impact' modules that monitor the key characteristics of food environments and three 'outcome' modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches ('minimal', 'expanded', 'optimal') to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Monitoring policy and actions on food environments: rationale and outline of the INFORMAS policy engagement and communication strategies.

The International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non-communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty-seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy-relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision-makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMAS's outputs have the greatest chance of being used to improve food environments.

Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index.

Government action is essential to increase the healthiness of food environments and reduce obesity, diet-related non-communicable diseases (NCDs), and their related inequalities. This paper proposes a monitoring framework to assess government policies and actions for creating healthy food environments. Recommendations from relevant authoritative organizations and expert advisory groups for reducing obesity and NCDs were examined, and pertinent components were incorporated into a comprehensive framework for monitoring government policies and actions. A Government Healthy Food Environment Policy Index (Food-EPI) was developed, which comprises a 'policy' component with seven domains on specific aspects of food environments, and an 'infrastructure support' component with seven domains to strengthen systems to prevent obesity and NCDs. These were revised through a week-long consultation process with international experts. Examples of good practice statements are proposed within each domain, and these will evolve into benchmarks established by governments at the forefront of creating and implementing food policies for good health. A rating process is proposed to assess a government's level of policy implementation towards good practice. The Food-EPI will be pre-tested and piloted in countries of varying size and income levels. The benchmarking of government policy implementation has the potential to catalyse greater action to reduce obesity and NCDs.

A proposed approach to monitor private-sector policies and practices related to food environments, obesity and non-communicable disease prevention.

Private-sector organizations play a critical role in shaping the food environments of individuals and populations. However, there is currently very limited independent monitoring of private-sector actions related to food environments. This paper reviews previous efforts to monitor the private sector in this area, and outlines a proposed approach to monitor private-sector policies and practices related to food environments, and their influence on obesity and non-communicable disease (NCD) prevention. A step-wise approach to data collection is recommended, in which the first ('minimal') step is the collation of publicly available food and nutrition-related policies of selected private-sector organizations. The second ('expanded') step assesses the nutritional composition of each organization's products, their promotions to children, their labelling practices, and the accessibility, availability and affordability of their products. The third ('optimal') step includes data on other commercial activities that may influence food environments, such as political lobbying and corporate philanthropy. The proposed approach will be further developed and piloted in countries of varying size and income levels. There is potential for this approach to enable national and international benchmarking of private-sector policies and practices, and to inform efforts to hold the private sector to account for their role in obesity and NCD prevention.

Monitoring the levels of important nutrients in the food supply.

A food supply that delivers energy-dense products with high levels of salt, saturated fats and trans fats, in large portion sizes, is a major cause of non-communicable diseases (NCDs). The highly processed foods produced by large food corporations are primary drivers of increases in consumption of these adverse nutrients. The objective of this paper is to present an approach to monitoring food composition that can both document the extent of the problem and underpin novel actions to address it. The monitoring approach seeks to systematically collect information on high-level contextual factors influencing food composition and assess the energy density, salt, saturated fat, trans fats and portion sizes of highly processed foods for sale in retail outlets (with a focus on supermarkets and quick-service restaurants). Regular surveys of food composition are proposed across geographies and over time using a pragmatic, standardized methodology. Surveys have already been undertaken in several high- and middle-income countries, and the trends have been valuable in informing policy approaches. The purpose of collecting data is not to exhaustively document the composition of all foods in the food supply in each country, but rather to provide information to support governments, industry and communities to develop and enact strategies to curb food-related NCDs.

Monitoring food and non-alcoholic beverage promotions to children.

Food and non-alcoholic beverage marketing is recognized as an important factor influencing food choices related to non-communicable diseases. The monitoring of populations' exposure to food and non-alcoholic beverage promotions, and the content of these promotions, is necessary to generate evidence to understand the extent of the problem, and to determine appropriate and effective policy responses. A review of studies measuring the nature and extent of exposure to food promotions was conducted to identify approaches to monitoring food promotions via dominant media platforms. A step-wise approach, comprising 'minimal', 'expanded' and 'optimal' monitoring activities, was designed. This approach can be used to assess the frequency and level of exposure of population groups (especially children) to food promotions, the persuasive power of techniques used in promotional communications (power of promotions) and the nutritional composition of promoted food products. Detailed procedures for data sampling, data collection and data analysis for a range of media types are presented, as well as quantifiable measurement indicators for assessing exposure to and power of food and non-alcoholic beverage promotions. The proposed framework supports the development of a consistent system for monitoring food and non-alcoholic beverage promotions for comparison between countries and over time.

Monitoring the health-related labelling of foods and non-alcoholic beverages in retail settings.

Food labelling on food packaging has the potential to have both positive and negative effects on diets. Monitoring different aspects of food labelling would help to identify priority policy options to help people make healthier food choices. A taxonomy of the elements of health-related food labelling is proposed. A systematic review of studies that assessed the nature and extent of health-related food labelling has been conducted to identify approaches to monitoring food labelling. A step-wise approach has been developed for independently assessing the nature and extent of health-related food labelling in different countries and over time. Procedures for sampling the food supply, and collecting and analysing data are proposed, as well as quantifiable measurement indicators and benchmarks for health-related food labelling.

Monitoring the price and affordability of foods and diets globally.

Food prices and food affordability are important determinants of food choices, obesity and non-communicable diseases. As governments around the world consider policies to promote the consumption of healthier foods, data on the relative price and affordability of foods, with a particular focus on the difference between 'less healthy' and 'healthy' foods and diets, are urgently needed. This paper briefly reviews past and current approaches to monitoring food prices, and identifies key issues affecting the development of practical tools and methods for food price data collection, analysis and reporting. A step-wise monitoring framework, including measurement indicators, is proposed. 'Minimal' data collection will assess the differential price of 'healthy' and 'less healthy' foods; 'expanded' monitoring will assess the differential price of 'healthy' and 'less healthy' diets; and the 'optimal' approach will also monitor food affordability, by taking into account household income. The monitoring of the price and affordability of 'healthy' and 'less healthy' foods and diets globally will provide robust data and benchmarks to inform economic and fiscal policy responses. Given the range of methodological, cultural and logistical challenges in this area, it is imperative that all aspects of the proposed monitoring framework are tested rigorously before implementation.