Slow and steady-small, but insufficient, changes in food and drink availability after four years of implementing a healthy food policy in New Zealand hospitals.

BACKGROUND: A voluntary National Healthy Food and Drink Policy (the Policy) was introduced in public hospitals in New Zealand in 2016. This study assessed the changes in implementation of the Policy and its impact on providing healthier food and drinks for staff and visitors in four district health boards between 1 and 5 years after the initial Policy introduction. METHODS: Repeat, cross-sectional audits were undertaken at the same eight sites in four district health boards between April and August 2017 and again between January and September 2021. In 2017, there were 74 retail settings audited (and 99 in 2021), comprising 27 (34 in 2021) serviced food outlets and 47 (65 in 2021) vending machines. The Policy's traffic light criteria were used to classify 2652 items in 2017 and 3928 items in 2021. The primary outcome was alignment with the Policy guidance on the proportions of red, amber and green foods and drinks (≥ 55% green 'healthy' items and 0% red 'unhealthy' items). RESULTS: The distribution of the classification of items as red, amber and green changed from 2017 to 2021 (p < 0.001) overall and in serviced food outlets (p < 0.001) and vending machines (p < 0.001). In 2021, green items were a higher proportion of available items (20.7%, n = 815) compared to 2017 (14.0%, n = 371), as were amber items (49.8%, n = 1957) compared to 2017 (29.2%, n = 775). Fewer items were classified as red in 2021 (29.4%, n = 1156) than in 2017 (56.8%, n = 1506). Mixed dishes were the most prevalent green items in both years, representing 11.4% (n = 446) of all items in 2021 and 5.5% (n = 145) in 2017. Fewer red packaged snacks (11.6%, n = 457 vs 22.5%, n = 598) and red cold drinks (5.2%, n = 205 vs 12.5%, n = 331) were available in 2021 compared to 2017. However, at either time, no organisation or setting met the criteria for alignment with the Policy (≥ 55% green items, 0% red items). CONCLUSIONS: Introduction of the Policy improved the relative healthiness of food and drinks available, but the proportion of red items remained high. More dedicated support is required to fully implement the Policy.

Differences in the cost and environmental impact between the current diet in Brazil and healthy and sustainable diets: a modeling study.

BACKGROUND: While healthy and sustainable diets benefit human and planetary health, their monetary cost has a direct impact on consumer food choices. This study aimed to identify the cost and environmental impact of the current Brazilian diet (CBD) and compare it with healthy and sustainable diets. METHODS: Data from the Brazilian Household Budget Survey 2017/18 and the Footprints of Foods and Culinary Preparations Consumed in Brazil database were used for a modeling study comparing the cost of healthy and sustainable diets (based on the Brazilian Dietary Guidelines (BDG) diet and the EAT-Lancet diet) versus the CBD. The DIETCOST program generated multiple food baskets for each scenario (Montecarlo simulations). Nutritional quality, cost, and environmental impact measures (carbon footprint (CF) and water footprint (WF)) were estimated for all diets and compared by ANOVA. Simple linear regressions used standardized environmental impacts measures to estimate differentials in costs and environmental impacts among diets scenarios. RESULTS: We observed significant differences in costs/1000 kcal. The BDG diet was cheaper (BRL$4.9 (95%IC:4.8;4.9) ≈ USD$1.5) than the CBD (BRL$5.6 (95%IC:5.6;5.7) ≈ USD$1.8) and the EAT-Lancet diet (BRL$6.1 (95%IC:6.0;6.1) ≈ USD$1.9). Ultra-processed foods (UPF) and red meat contributed the most to the CBD cost/1000 kcal, while fruits and vegetables made the lowest contribution to CBD. Red meat, sugary drinks, and UPF were the main contributors to the environmental impacts of the CBD. The environmental impact/1000 kcal of the CBD was nearly double (CF:3.1 kg(95%IC: 3.0;3.1); WF:2,705 L 95%IC:2,671;2,739)) the cost of the BDG diet (CF:1.4 kg (95%IC:1.4;1.4); WF:1,542 L (95%IC:1,524;1,561)) and EAT-Lancet diet (CF:1.1 kg (95%IC:1.0;1.1); WF:1,448 L (95%IC:1,428;1,469)). A one standard deviation increase in standardized CF corresponded to an increase of BRL$0.48 in the cost of the CBD, similar to standardized WF (BRL$0.56). A similar relationship between the environmental impact and the cost of the BDG (CF: BRL$0.20; WF: BRL$0.33) and EAT-Lancet (CF: BRL$0.04; WF: BRL$0.18) was found, but with a less pronounced effect. CONCLUSIONS: The BDG diet was cost-effective, while the EAT-Lancet diet was slightly pricier than the CBD. The CBD presented almost double the CF and WF compared to the BDG and EAT-Lancet diets. The lower cost in each diet was associated with lower environmental impact, particularly for the BDG and EAT-Lancet diets. Multisectoral public policies must be applied to guide individuals and societies towards healthier and more sustainable eating patterns.

Awareness, support, and opinions of healthy food and drink policies: a survey of staff and visitors in New Zealand healthcare organisations.

BACKGROUND: In 2016, a voluntary National Healthy Food and Drink Policy (hereafter, "the Policy") was released to encourage public hospitals in New Zealand to provide food and drink options in line with national dietary guidelines. Five years later, eight (of 20) organisations had adopted it, with several preferring to retain or update their own institutional-level version. This study assessed staff and visitors' awareness and support for and against the Policy, and collected feedback on perceived food environment changes since implementation of the Policy. METHODS: Cross-sectional electronic and paper-based survey conducted from June 2021 to August 2022. Descriptive statistics were used to present quantitative findings. Free-text responses were analysed following a general inductive approach. Qualitative and quantitative findings were compared by level of implementation of the Policy, and by ethnicity and financial security of participants. RESULTS: Data were collected from 2,526 staff and 261 visitors in 19 healthcare organisations. 80% of staff and 56% of visitors were aware of the Policy. Both staff and visitors generally supported the Policy, irrespective of whether they were aware of it or not, with most agreeing that "Hospitals should be good role models." Among staff who opposed the Policy, the most common reason for doing so was freedom of choice. The Policy had a greater impact, positive and negative, on Maori and Pacific staff, due to more frequent purchasing onsite. Most staff noticed differences in the food and drinks available since Policy implementation. There was positive feedback about the variety of options available in some hospitals, but overall 40% of free text comments mentioned limited choice. 74% of staff reported that food and drinks were more expensive. Low-income staff/visitors and shift workers were particularly impacted by reduced choice and higher prices for healthy options. CONCLUSIONS: The Policy led to notable changes in the healthiness of foods and drinks available in NZ hospitals but this was accompanied by a perception of reduced value and choice. While generally well supported, the findings indicate opportunities to improve implementation of food and drink policies (e.g. providing more healthy food choices, better engagement with staff, and keeping prices of healthy options low) and confirm that the Policy could be expanded to other public workplaces.

The utilisation of legal instruments by United Nations actors to restrict the exposure of children to unhealthy food and beverage marketing: a qualitative content analysis of UN instruments.

INTRODUCTION: United Nations (UN) agencies are influential global health actors that can introduce legal instruments to call on Member States to act on pressing issues. This paper examines the deployment and strength of global health law instruments used by UN actors to call on Member States to restrict the exposure of children to unhealthy food and beverage marketing. METHODS: Global health law instruments were identified from a review of four UN agencies that have a mandate over children's exposure to marketing of unhealthy food and beverage products namely: the World Health Organization (WHO); the Food and Agriculture Organization (FAO); the United Nations General Assembly (UNGA) and the UN Office of the High Commissioner for Human Rights (OHCHR). Data on marketing restrictions were extracted and coded and descriptive qualitative content analysis was used to assess the strength of the instruments. RESULTS: A wide range of instruments have been used by the four agencies: seven by the WHO; two by the FAO; three by the UNGA; and eight by the UN human rights infrastructure. The UN human rights instruments used strong, consistent language and called for government regulations to be enacted in a directive manner. In contrast, the language calling for action by the WHO, FAO and UNGA was weaker, inconsistent, did not get stronger over time and varied according to the type of instrument used. CONCLUSION: This study suggests that a child rights-based approach to restricting unhealthy food and beverage marketing to children would be supported by strong human rights legal instruments and would allow for more directive recommendations to Member States than is currently provided by WHO, FAO and UNGA. Strengthening the directives in the instruments to clarify Member States' obligations using both WHO and child rights mandates would increase the utility of global health law and UN actors' influence.

The prevalence of vegetarians, vegans and other dietary patterns that exclude some animal-source foods in a representative sample of New Zealand adults.

OBJECTIVE: This study aimed to estimate the prevalence of vegetarians, vegans and other dietary patterns that exclude some animal-source foods in New Zealand adults. We also examined socio-demographic and lifestyle correlates of these dietary patterns. DESIGN: The New Zealand Health Survey is a representative rolling cross-sectional survey of New Zealanders; data from the 2018/19 and 2019/20 waves were used for this analysis. Participants were asked if they completely excluded red meat, poultry, fish/shellfish, eggs or dairy products from their diet. SETTING: New Zealand. PARTICIPANTS: Adults, aged ≥ 15 years (n 23 292). RESULTS: The prevalence of red-meat excluders (2·89 %), pescatarians (1·40 %), vegetarians (2·04 %) and vegans (0·74 %) was low. After adjustment for socio-demographic and lifestyle factors, women (OR = 1·54, 95 % CI: 1·22, 1·95), Asian people (OR = 2·56, 95 % CI: 1·96, 4·45), people with tertiary education (OR = 1·71, 95 % CI: 1·18, 2·48) and physically active people (OR = 1·36, 95 % CI: 1·04, 1·76) were more likely to be vegetarian/vegan. Those aged ≥ 75 years (OR = 0·28, 95 % CI: 0·14, 0·53) and current smokers (OR = 0·42, 95 % CI: 0·23, 0·76) were less likely to be vegetarian/vegan. Similar associations were seen between socio-demographic and lifestyle factors and the odds of being a red-meat excluder/pescatarian. CONCLUSIONS: Approximately 93 % of New Zealand adults eat red meat and a very small number exclude all animal products from their diets. The Eating and Activity Guidelines for New Zealand adults recommend a plant-based diet with moderate amounts of animal-source foods. A comprehensive national nutrition survey would provide detailed information on the amount of red meat and other animal-source foods that the New Zealand population currently consumes.

Designing legislative responses to restrict children's exposure to unhealthy food and non-alcoholic beverage marketing: a case study analysis of Chile, Canada and the United Kingdom.

INTRODUCTION: Introducing legislation that restricts companies from exposing children to marketing of unhealthy food and beverage products is both politically and technically difficult. To advance the literature on the technical design of food marketing legislation, and to support governments around the world with legislative development, we aimed to describe the legislative approach from three governments. METHODS: A multiple case study methodology was adopted to describe how three governments approached designing comprehensive food marketing legislation (Chile, Canada and the United Kingdom). A conceptual framework outlining best practice design principles guided our methodological approach to examine how each country designed the technical aspects of their regulatory response, including the regulatory form adopted, the substantive content of the laws, and the implementation and governance mechanisms used. Data from documentary evidence and 15 semi-structured key informant interviews were collected and synthesised using a directed content analysis. RESULTS: All three countries varied in their legislative design and were therefore considered of variable strength regarding the legislative elements used to protect children from unhealthy food marketing. When compared against the conceptual framework, some elements of best practice design were present, particularly relating to the governance of legislative design and implementation, but the scope of each law (or proposed laws) had limitations. These included: the exclusion of brand marketing; not protecting children up to age 18; focusing solely on child-directed marketing instead of all marketing that children are likely to be exposed to; and not allocating sufficient resources to effectively monitor and enforce the laws. The United Kingdom's approach to legislation is the most comprehensive and more likely to meet its regulatory objectives. CONCLUSIONS: Our synthesis and analysis of the technical elements of food marketing laws can support governments around the world as they develop their own food marketing restrictions. An analysis of the three approaches illustrates an evolution in the design of food marketing laws over time, as well as the design strengths offered by a legislative approach. Opportunities remain for strengthening legislative responses to protect children from unhealthy food marketing practices.

Unhealthy food and beverage marketing to children on digital platforms in Aotearoa, New Zealand.

BACKGROUND: Children's exposure to unhealthy food and beverage marketing has a direct impact on their dietary preference for, and consumption of, unhealthy food and drinks. Most children spend time online, yet marketing restrictions for this medium have had slow uptake globally. A voluntary Children's and Young People's Advertising (CYPA) Code was implemented in Aotearoa, New Zealand (NZ) in 2017. This study explores the Code's limitations in protecting children from harmful food and beverage marketing practices on digital platforms accessible to children. METHODS: A cross-sectional content analysis of company websites (n = 64), Facebook pages (n = 32), and YouTube channels (n = 15) of the most popular food and beverage brands was conducted between 2019 and 2021 in NZ. Brands were selected based on market share, web traffic analysis and consumer engagement (Facebook page 'Likes' and YouTube page views). Analysis focused on volume and type of food posts/videos, level of consumer interaction, nutritional quality of foods pictured (based on two different nutrient profile models), and use of specific persuasive marketing techniques. RESULTS: Eighty-one percent of websites (n = 52) featured marketing of unhealthy food and beverages. Thirty-five percent of websites featuring unhealthy food and beverages used promotional strategies positioning their products as 'for kids'; a further 13% used 'family-oriented' messaging. Several websites featuring unhealthy products also had designated sections for children, 'advergaming,' or direct messaging to children. Eighty-five percent of all food and drink company Facebook posts and YouTube videos were classified as unhealthy. Twenty-eight percent of Facebook posts for unhealthy products featured persuasive promotional strategies, and 39% premium offers. Nearly 30% of YouTube videos for unhealthy food and beverages featured promotional strategies, and 13% premium offers. Ten percent of Facebook posts and 13% of YouTube videos of unhealthy food and beverages used marketing techniques specifically targeting children and young people. CONCLUSIONS: The voluntary CYPA Code has been in effect since 2017, but the inherent limitations and loopholes in the Code mean companies continue to market unhealthy food and beverages in ways that appeal to children even if they have committed to the Code. Comprehensive and mandatory regulation would help protect children from exposure to harmful marketing.

Implementing healthy food environment policies in New Zealand: nine years of inaction.

BACKGROUND: The INFORMAS [International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support] Healthy Food Environment Policy Index (Food-EPI) was developed to evaluate the degree of implementation of widely recommended food environment policies by national governments against international best practice, and has been applied in New Zealand in 2014, 2017 and 2020. This paper outlines the 2020 Food-EPI process and compares policy implementation and recommendations with the 2014 and 2017 Food-EPI. METHODS: In March-April 2020, a national panel of over 50 public health experts participated in Food-EPI. Experts rated the extent of implementation of 47 "good practice" policy and infrastructure support indicators compared to international best practice, using an extensive evidence document verified by government officials. Experts then proposed and prioritized concrete actions needed to address the critical implementation gaps identified. Progress on policy implementation and recommendations made over the three Food-EPIs was compared. RESULTS: In 2020, 60% of the indicators were rated as having "low" or "very little, if any" implementation compared to international benchmarks: less progress than 2017 (47%) and similar to 2014 (61%). Of the nine priority actions proposed in 2014, there was only noticeable action on one (Health Star Ratings). The majority of actions were therefore proposed again in 2017 and 2020. In 2020 the proposed actions were broader, reflecting the need for multisectoral action to improve the food environment, and the need for a mandatory approach in all policy areas. CONCLUSIONS: There has been little to no progress in the past three terms of government (9 years) on the implementation of policies and infrastructure support for healthy food environments, with implementation overall regressing between 2017 and 2020. The proposed actions in 2020 have reflected a growing movement to locate nutrition within the wider context of planetary health and with recognition of the social determinants of health and nutrition, resulting in recommendations that will require the involvement of many government entities to overcome the existing policy inertia. The increase in food insecurity due to COVID-19 lockdowns may provide the impetus to stimulate action on food polices.

Impact of a voluntary industry code for advertising food to children and young people: an analysis of New Zealand television data.

OBJECTIVE: To evaluate the impact of the 2017 update to the voluntary Advertising Standards Authority (ASA) code for advertising food on children and young people's exposure to unhealthy food advertisements on New Zealand television. DESIGN: Audience ratings data were analysed for New Zealand children and young people's television viewing for eight random days prior to (June to August 2015) and following (October to December 2018) the code update, from 06.00 to midnight (864 h). Food advertisements were coded using three nutrient profiling models. The number of children and young people watching television each year was compared. SETTING: Three free-to-air New Zealand television channels. PARTICIPANTS: New Zealand children aged 5-18 years. RESULTS: Television viewer numbers decreased over the 3 years (P < 0·0001). The mean rate of unhealthy food advertising on weekdays was 10·4 advertisements/h (2015) and 9·5 advertisements/h (2018). Corresponding rates for weekend days were 8·1 and 7·3 advertisements/h, respectively. The percentage of food advertisements which were for unhealthy foods remained high (63·7 % on weekdays and 65·9 % on weekends) in 2018. The ASA definition of children's 'peak viewing time' (when 25 % of the audience are children) did not correspond to any broadcast times across weekdays and weekend days. CONCLUSIONS: Between 2015 and 2018, children and young people's television exposure to unhealthy food advertising decreased. However, almost two-thirds of all food advertisements were still unhealthy, and the updated ASA code excluded the times when the greatest number of children was watching television. Consequently, government regulation and regular monitoring should reflect the evolving food marketing environment.

Seven-year trends in the availability, sugar content and serve size of single-serve non-alcoholic beverages in New Zealand: 2013-2019.

OBJECTIVE: To assess trends in relative availability, sugar content and serve size of ready-to-drink non-alcoholic beverages available for sale in supermarkets from 2013 to 2019. DESIGN: Repeat cross-sectional surveys. Data on single-serve beverages to be consumed in one sitting were obtained from an updated brand-specific food composition database. Trends in beverages availability and proportions with serve size ≤ 250 ml were assessed by χ2 tests. Sugar content trends were examined using linear regressions. The proportion of beverages exceeding the sugar threshold of the United Kingdom Soft Drinks Industry Levy (SDIL) was assessed. SETTING: New Zealand. RESULTS: From 2013 to 2019, there was (i) an increase in the availability of sugar-free/low-sugar beverages (n 25 (8·4 %) to n 75 (19·1 %); P < 0·001) and craft sugar-sweetened soft drinks (n 11 (3·7 %) to n 36 (9·2 %); P < 0·001), and a decrease in availability of fruit/vegetable juices/drinks (n 94 (31·8 %) to n 75 (19·4 %); P < 0·001); (ii) small decreases in sugar content (mean g/100 ml) of sugar-sweetened soft drinks (3·03; 95 % CI 3·77, 2·29); fruit/vegetable juices/drinks (1·08; 95 % CI 2·14, 0·01) and energy drinks (0·98; 95 % CI 1·63, 0·32) and (iii) slight reduction in the proportion of beverages with serve size ≤ 250 ml (21·6 to 18·9 %; P < 0·001). In 2019, most beverages were sugar-sweetened or had naturally occurring sugars (79·1 %) and serve size > 250 ml (81·1 %) and most sugar-sweetened beverages exceeded the SDIL lower benchmark (72·9 %). CONCLUSIONS: Most single-serve beverages available for sale in 2019 were sugary drinks with high sugar content and large serve sizes; therefore, changes made across the years were not meaningful for population's health.

Measuring cost and affordability of current vs. healthy diets in Argentina: an application of linear programming and the INFORMAS protocol.

BACKGROUND: Food cost and affordability is one of the main barriers to improve the nutritional quality of diets of the population. However, in Argentina, where over 60% of adults and 40% of children and adolescents are overweight or obese, little is known about the difference in cost and affordability of healthier diets compared to ordinary, less healthy ones. METHODS: We implemented the "optimal approach" proposed by the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS). We modelled the current diet and two types of healthy diets, one equal in energy with the current diet and one 6.3% lower in energy by linear programming. Cost estimations were performed by collecting food product prices and running a Monte Carlo simulation (10,000 iterations) to obtain a range of costs for each model diet. Affordability was measured as the percentage contribution of diet cost vs. average household income in average, poor and extremely poor households and by income deciles. RESULTS: On average, households must spend 32% more money on food to ensure equal energy intake from a healthy diet than from a current model diet. When the energy intake target was reduced by 6.3%, the difference in cost was 22%. There are no reasonably likely situations in which any of these healthy diets could cost less or the same than the current unhealthier one. Over 50% of households would be unable to afford the modelled healthy diets, while 40% could not afford the current diet. CONCLUSIONS: Differential cost and affordability of healthy vs. unhealthy diets are germane to the design of effective public policies to reduce obesity and NCDs in Argentina. It is necessary to implement urgent measures to transform the obesogenic environment, making healthier products more affordable, available and desirable, and discouraging consumption of nutrient-poor, energy-rich foods.

Modelling the cost differential between healthy and current diets: the New Zealand case study.

BACKGROUND: Evidence on whether healthy diets are more expensive than current diets is mixed due to lack of robust methodology. The aim of this study was to develop a novel methodology to model the cost differential between healthy and current diets and apply it in New Zealand. METHODS: Prices of common foods were collected from 15 supermarkets, 15 fruit/vegetable stores and from the Food Price Index. The distribution of the cost of two-weekly healthy and current household diets was modelled using a list of commonly consumed foods, a set of min and max quantity/serves constraints for each, and food group and nutrient intakes based on dietary guidelines (healthy diets) or nutrition survey data (current diets). The cost differential between healthy and current diets was modelled for several diet, prices and policy scenarios. Acceptability of resulting meal plans was validated. RESULTS: The average cost of healthy household diets was $27 more expensive than the average cost of current diets, but 25.8% of healthy diets were cheaper than the average cost of current diets. This cost differential could be reduced if fruits and vegetables became exempt from Goods and Services Tax. Healthy diets were cheaper with an allowance for discretionary foods and more expensive when including takeaway meals. For Maori and Pacific households, healthy diets were on average $40 and $60 cheaper than current diets due to large energy intakes. Discretionary foods and takeaway meals contributed 30-40% to the average cost of current diets. CONCLUSION: Healthy New Zealand diets were on average more expensive than current diets, but one-quarter of healthy diets were cheaper than the average cost of current diets. The impact of diet composition, types of prices and policies on the cost differential was substantial. The methodology can be used in other countries to monitor the cost differential between healthy and current household diets.

Measuring and stimulating progress on implementing widely recommended food environment policies: the New Zealand case study.

BACKGROUND: Monitoring the degree of implementation of widely recommended food environment policies by national governments is an important part of stimulating progress towards better population nutritional health. METHODS: The Healthy Food Environment Policy Index (Food-EPI) was applied for the second time in New Zealand in 2017 (initially applied in 2014) to measure progress on implementation of widely recommended food environment policies. A national panel of 71 independent (n = 48) and government (n = 23) public health experts rated the extent of implementation of 47 policy and infrastructure support good practice indicators by the Government against international best practice, using an extensive evidence document verified by government officials. Experts proposed and prioritised concrete actions needed to address the critical implementation gaps identified. RESULTS: Inter-rater reliability was good (Gwet's AC2 > 0.8). Approximately half (47%) of the indicators were rated as having 'low' or 'very little, if any' implementation compared to international benchmarks, a decrease since 2014 (60%). A lower proportion of infrastructure support (29%) compared to policy (70%) indicators were rated as having 'low' or 'very little, if any' implementation. The experts recommended 53 actions, prioritising nine for immediate implementation; three of those prioritised actions were the same as in 2014. The vast majority of experts agreed that the Food-EPI is likely to contribute to beneficial policy change and increased their knowledge about food environments and policies. CONCLUSION: The Food-EPI has the potential to increase accountability of governments to implement widely recommended food environment policies and reduce the burden of obesity and diet-related diseases.

Paying for convenience: comparing the cost of takeaway meals with their healthier home-cooked counterparts in New Zealand.

OBJECTIVE: Convenience and cost impact on people's meal decisions. Takeaway and pre-prepared foods save preparation time but may contribute to poorer-quality diets. Analysing the impact of time on relative cost differences between meals of varying convenience contributes to understanding the barrier of time to selecting healthy meals. DESIGN: Six popular New Zealand takeaway meals were identified from two large national surveys and compared with similar, but healthier, home-made and home-assembled meals that met nutrition targets consistent with New Zealand Eating and Activity Guidelines. The cost of each complete meal, cost per kilogram, and confidence intervals of the cost of each meal type were calculated. The time-inclusive cost was calculated by adding waiting or preparation time cost at the minimum wage. SETTING: A large urban area in New Zealand. RESULTS: For five of six popular meals, the mean cost of the home-made and home-assembled meals was cheaper than the takeaway meals. When the cost of time was added, all home-assembled meal options were the cheapest and half of the home-made meals were at least as expensive as the takeaway meals. The home-prepared meals were designed to provide less saturated fat and Na and more vegetables than their takeaway counterparts; however, the home-assembled meals provided more Na than the home-made meals. CONCLUSIONS: Healthier home-made and home-assembled meals were, except one, cheaper options than takeaways. When the cost of time was added, either the home-made or the takeaway meal was the most expensive. This research questions whether takeaways are better value than home-prepared meals.

Testing a nutrient composition threshold model to classify brands for marketing restrictions.

INTRODUCTION: Food marketing restrictions often apply nutrient profile models (NPM) to distinguish unhealthy products that should not be advertised, however brand-only marketing remains largely unaddressed. We sought to test a threshold method for classifying packaged food, beverage, or fast-food brands as (non)permitted for marketing, based on the nutrient profile of their product-lines. METHODS: We retrieved nutrient information from the Nutritrack databases for all products sold by the top 51 packaged food, beverage and fast-food brands in New Zealand, selected by market share. All products under each brand were classified as permitted (or not) to be marketed to children, using the NPM for WHO Western Pacific. The 25%, 50%, 75% and 90% threshold of brands' products permitted to market were compared. The 50% and 75% thresholds were compared to the WHO CLICK method, which is based on assessment of the brand's leading product. RESULTS: The 90% threshold permitted 13% of the brands to be marketed to children. The 25% threshold permitted the marketing of 62% of brands. The 50% and 75% thresholds remained highly sensitive in identifying brands that should not be marketed to children. Comparison to the WHO CLICK method identified that a threshold method is more comprehensive and less arbitrary. CONCLUSIONS: A threshold model based on product-line nutrient profiling provides a robust and option for brand classification. The 50% and 75% thresholds may be the most politically preferred options for use in regulation, while remaining highly effective. PRACTITIONER POINTS: Brand marketing (e.g. sponsorship) remains largely unaddressed in existing restrictions on unhealthy food and beverage marketing to children.An established Nutrient Profile Model can be applied to a brand's entire product line, allowing calculation of the proportion of products that would not be permitted to be advertised to children.Restricting brand marketing for food and beverage brands with less than 50% or 75% of their products classified as 'permitted to be marketed to children' is a robust and evidence-based method that can be applied in regulation, with potential to mitigate industry challenges.

The development of sodium reduction targets for New Zealand fast foods and a comparison with the current sodium contents of products.

Sodium intake attributed to fast food is increasing globally. This research aims to develop maximum sodium reduction targets for New Zealand (NZ) fast foods and compare them with the current sodium content of products. Sodium content and serving size data were sourced from an existing database of major NZ fast-food chains. Target development followed a step-by-step process, informed by international targets and serving sizes, and previous methods for packaged supermarket foods. Sodium reduction targets were set per 100 g and serving, using a 40% reduction in the mean sodium content or the value met by 35-45% of products. Thirty-four per cent (1797/5246) of products in the database had sodium data available for target development. Sodium reduction targets were developed for 17 fast-food categories. Per 100 g targets ranged from 158 mg for 'Other salads' to 665 mg for 'Mayonnaise and dressings'. Per serving targets ranged from 118 mg for 'Sauce' to 1270 mg for 'Burgers with cured meat'. The largest difference between the current mean sodium content and corresponding target was for 'Other salads' and 'Grilled Chicken' (both -40% per 100g) and 'Fries and potato products' (-45% per serving), and the smallest, 'Pizza with cured meat toppings' (-3% per 100 g) and 'Pies, tarts, sausage rolls and quiches' (-4% per serving). The results indicate the display of nutrition information should be mandated and there is considerable room for sodium reduction in NZ fast foods. The methods described provide a model for other countries to develop country-specific, fast-food sodium reduction targets.

Implementing healthy food policies in health sector settings: New Zealand stakeholder perspectives.

BACKGROUND: In 2016, a voluntary National Healthy Food and Drink Policy was released to improve the healthiness of food and drinks for sale in New Zealand health sector organisations. The Policy aims to role model healthy eating and demonstrate commitment to health and well-being of hospital staff and visitors and the general public. This study aimed to understand the experiences of hospital food providers and public health dietitians/staff in implementing the Policy, and identify tools and resources needed to assist with the implementation. METHODS: A maximum variation purposive sampling strategy (based on a health district's population size and food outlet type) was used to recruit participants by email. Video conference or email semi-structured interviews included 15 open-ended questions that focused on awareness, understanding of, and attitudes towards the Policy; level of support received; perceived customer response; tools and resources needed to support implementation; and unintended or unforeseen consequences. Data was analysed using a reflexive thematic analysis approach. RESULTS: Twelve participants (eight food providers and four public health dietitians/staff) were interviewed; three from small (< 100,000 people), four from medium (100,000-300,000 people) and five from large (> 300,000 people) health districts. There was agreement that hospitals should role model healthy eating for the wider community. Three themes were identified relating to the implementation of the Policy: (1) Complexities of operating food outlets under a healthy food and drink policy in public health sector settings; (2) Adoption, implementation, and monitoring of the Policy as a series of incoherent ad-hoc actions; and (3) Policy is (currently) not achieving the desired impact. Concerns about increased food waste, loss of profits and an uneven playing field between food providers were related to the voluntary nature of the unsupported Policy. Three tools could enable implementation: a digital monitoring tool, a web-based database of compliant products, and customer communication materials. CONCLUSIONS: Adopting a single, mandatory Policy, provision of funding for implementation actions and supportive tools, and good communication with customers could facilitate implementation. Despite the relatively small sample size and views from only two stakeholder groups, strategies identified are relevant to policy makers, healthcare providers and public health professionals.

Barriers and facilitators to implementation of healthy food and drink policies in public sector workplaces: a systematic literature review.

CONTEXT: Many countries and institutions have adopted policies to promote healthier food and drink availability in various settings, including public sector workplaces. OBJECTIVE: The objective of this review was to systematically synthesize evidence on barriers and facilitators to implementation of and compliance with healthy food and drink policies aimed at the general adult population in public sector workplaces. DATA SOURCES: Nine scientific databases, 9 grey literature sources, and government websites in key English-speaking countries along with reference lists. DATA EXTRACTION: All identified records (N = 8559) were assessed for eligibility. Studies reporting on barriers and facilitators were included irrespective of study design and methods used but were excluded if they were published before 2000 or in a non-English language. DATA ANALYSIS: Forty-one studies were eligible for inclusion, mainly from Australia, the United States, and Canada. The most common workplace settings were healthcare facilities, sports and recreation centers, and government agencies. Interviews and surveys were the predominant methods of data collection. Methodological aspects were assessed with the Critical Appraisal Skills Program Qualitative Studies Checklist. Generally, there was poor reporting of data collection and analysis methods. Thematic synthesis identified 4 themes: (1) a ratified policy as the foundation of a successful implementation plan; (2) food providers' acceptance of implementation is rooted in positive stakeholder relationships, recognizing opportunities, and taking ownership; (3) creating customer demand for healthier options may relieve tension between policy objectives and business goals; and (4) food supply may limit the ability of food providers to implement the policy. CONCLUSIONS: Findings suggest that although vendors encounter challenges, there are also factors that support healthy food and drink policy implementation in public sector workplaces. Understanding barriers and facilitators to successful policy implementation will significantly benefit stakeholders interested or engaging in healthy food and drink policy development and implementation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021246340.

Evaluating User Experiences and Preferred Features of a Web-Based 24-Hour Dietary Assessment Tool: Usability Study.

BACKGROUND: Intake24, a web-based 24-hour dietary recall tool developed in the United Kingdom, was adapted for use in New Zealand (Intake24-NZ) through the addition of a New Zealand food list, portion size images, and food composition database. Owing to the customizations made, a thorough evaluation of the tool's usability was required. Detailed qualitative usability studies are well suited to investigate any challenges encountered while completing a web-based 24-hour recall and provide meaningful data to inform enhancements to the tool. OBJECTIVE: This study aims to evaluate the usability of Intake24-NZ and identify improvements to enhance both the user experience and the quality of dietary intake data collected. METHODS: We used a mixed methods approach comprising two components: (1) completion of a single 24-hour dietary recall using Intake24-NZ with both screen observation recordings and collation of verbal participant feedback on their experience and (2) a survey. RESULTS: A total of 37 participants aged ≥11 years self-completed the dietary recall and usability survey (men and boys: 14/37, 38% and women and girls: 23/37, 62%; Maori: 10/37, 27% and non-Maori: 27/37, 73%). Although most (31/37, 84%) reported that Intake24-NZ was easy to use and navigate, data from the recorded observations and usability survey revealed challenges related to the correct use of search terms, search results obtained (eg, type and order of foods displayed), portion size estimation, and associated food prompts (eg, did you add milk to your tea?). CONCLUSIONS: This comprehensive usability study identified challenges experienced by users in completing a dietary recall in Intake24-NZ. The results informed a series of improvements to enhance user experience and the quality of dietary data collected with Intake24-NZ, including adding new foods to the food list, optimizing the search function and ordering of search results, creating new portion size images, and providing clearer instructions to the users.

Conference on 'nutrition and wellbeing in Oceania'.

Oceania is currently facing a substantial challenge: to provide sustainable and ethical food systems that support nutrition and health across land and water. The Nutrition Society of Australia and the Nutrition Society of New Zealand held a joint 2023 Annual Scientific Meeting on 'Nutrition and Wellbeing in Oceania' attended by 408 delegates. This was a timely conference focussing on nutrition challenges across the Pacific, emphasising the importance of nutrition across land and water, education settings, women's health and gut health. Cutting-edge, multi-disciplinary and collaborative research was presented in a 4-day programme of keynote presentations, workshops, oral and poster sessions, breakfast and lunch symposiums and early career researcher sessions. The conference highlighted the importance of collaboration between nations to address the challenge facing nutrition and wellbeing across Oceania. A systems approach of collaboration among scientists, industry and government is vital for finding solutions to this challenge.