School-based learning about sugary drinks: possibilities and potential for curriculum approaches supporting health promotion in New Zealand.

Achieving greater alignment with national curriculum and local school and teacher objectives alongside a deeper understanding of student needs can enhance the impact and reach of health promotion interventions. This study reports on teacher perspectives of a multi-pathway curriculum outline supporting learning (Grades 7-9) about sugary drinks. The outline was developed to support scale-up and sustainability of a successful sugary drink intervention trialed in four New Zealand secondary schools. Sixteen teachers from a range of subjects provided input via focus groups. Inductive qualitative thematic analysis was used to identify and interpret patterns within the data. Sugary drinks were perceived to be an important and engaging learning context. Teachers valued the potential long-term societal benefits of health-based learning and benefits to individual students and their families. They recognised students as health communicators and influencers within families and communities. Relevance to students' lives and alignment with national curriculum and assessment objectives and teacher subject expertise were key factors in learning pathway selection. Teacher support is crucial in facilitating sustainable school-based health promotion, which often does not sit within a single curriculum area. Factors such as these, that teachers prioritise in their curriculum decision-making, must be understood and leveraged in school-based health promotion research.

Children's scabies survey indicates high prevalence and misdiagnosis in Auckland educational institutions.

AIM: Here, we present results of a survey of scabies prevalence in childcare centres and primary schools in Auckland. METHODS: Children whose parents agreed to take part in participating centres in the Auckland region were examined for scabies by general practitioners and given questionnaires of relevant symptoms. Diagnoses of clinical or suspected scabies were made according to the International Alliance for the Control of Scabies (IACS) criteria. The survey was a stratified random sample of schools and early childcare centres. A quantitative polymerase chain reaction (PCR) test was also used to complement the IACS criteria. RESULTS: A total of 181 children were examined, with 145 children with history information, 16 of whom (11.0%) met the criteria for 'clinical' or 'suspected' scabies. Weighted analysis, accounting for the survey design, indicated that the prevalence of scabies in early childcare centres was 13.2% (95% CI: 4.3 to 22.1), with no school-aged children fulfilling these criteria. A higher proportion had clinical signs of scabies with 23 (12.7%) having typical scabies lesions and a further 43 (23.8%) had atypical lesions. A total of 64 PCR tests were taken and 15 (23%) were positive. None of these cases were receiving treatment for scabies. Five were undergoing topical skin treatment: three with topical steroid and two with calamine lotion. CONCLUSIONS: The prevalence of children with scabies is high in early childcare centres in Auckland. Misdiagnosis is suggested by several PCR positive cases being treated by topical agents used to treat other skin conditions.

High prevalence of scabies in Auckland pre-schools.

AIM: Scabies is a difficult disease to diagnose and its prevalence not well established. A strong association between scabies and more serious illnesses in children, for instance acute rheumatic fever, suggests greater understanding of scabies prevalence is warranted. Here, we present initial findings of a study of childcare centres, to estimate the prevalence of scabies in the Auckland community. METHODS: Children in three childcare centres from socio-economically challenged areas were examined for scabies. Diagnoses were made according to the International Alliance for the Control of Scabies (IACS) criteria, whose "clinical" or "suspected" definition consists of examination findings of papules: either "typical" or "atypical" distribution, along with history features of itch and contact with likely other cases. A quantitative polymerase chain reaction (qPCR) test was also used. RESULTS: A total of 67 children were examined, with over half (n=38 or 56.7%) showing signs of typical (14; 20.9%) or atypical (24; 35.8%) scabies lesions. History information was available for 50 children. Of these, nine (18%) met the criteria for "clinical" or "suspected" scabies. Of 27 qPCR tests performed nine (33%) tested positive. CONCLUSION: The prevalence of scabies is high in early childcare centres in socio-economically challenged areas of Auckland.

Gamification and Sugar: A School-Based Pilot Study of Social Marketing and Gamification Approaches to Reduce Sugary Drink Intake in Pasifika School Students.

The aim of this study was to investigate a social marketing-gamification intervention to reduce sugary drink intake drawing on popular culture of Pasifika secondary school students in Auckland, New Zealand. Students aged 11 to 14 years from one coeducational high school participated in the 11-week pilot study. The 9-week intervention was undertaken in assemblies and classrooms. Baseline and follow-up measures were completed by 227 and 220 students, respectively, of 298 enrolled students. Retention of the "3-6-9" teaching related to maximum daily sugar intake increased from 9% at baseline to 97% at follow-up (P < .0001). Significant increases were observed of students who correctly answered sugar content of drinks. Overall consumption of sugary drink decreased at follow-up by 0.46 glasses per day. The main conclusion from this study was that this school-based gamification educational package to convey messages about sugar content of drinks using popular modes of engagement is a promising intervention that was acceptable and well supported by school staff and students.

Estimating the effect of selective border relaxation on COVID-19 in New Zealand.

AIMS: We developed a model, updated daily, to estimate undetected COVID-19 infections exiting quarantine following selectively opening New Zealand's borders to travellers from low-risk countries. METHODS: The prevalence of infectious COVID-19 cases by country was multiplied by expected monthly passenger volumes to predict the rate of arrivals. The rate of undetected infections entering the border following screening and quarantine was estimated. Level 1, Level 2 and Level 3 countries were defined as those with an active COVID-19 prevalence of up to 1/105, 10/105 and 100/105, respectively. RESULTS: With 65,272 travellers per month, the number of undetected COVID-19 infections exiting quarantine is 1 every 45, 15 and 31 months for Level 1, Level 2 and Level 3 countries, respectively. The overall rate of undetected active COVID-19 infections exiting quarantine is expected to increase from the current 0.40 to 0.50 per month, or an increase of one extra infection every 10 months. CONCLUSIONS: Loosening border restrictions results in a small increase in the rate of undetected COVID-19 infections exiting quarantine, which increases from the current baseline by one infection every 10 months. This information may be useful in guiding decision-making on selectively opening of borders in the COVID-19 era.

What factors are associated with early childhood dental caries? A longitudinal study of the Growing Up in New Zealand cohort.

BACKGROUND: The relative importance of different strategies to prevent dental caries is not known. AIM: We explored the relationship between oral health behaviours, diet, and the incidence of dental caries. DESIGN: We conducted a study of children participating in the 'Growing Up in New Zealand' cohort. Exposures were oral health behaviours, a food frequency questionnaire, and sociodemographic characteristics that were recorded when the child was nine months and two years old. Outcomes were records of dental caries at ages four to seven years. RESULTS: 4111 children had dental examination records from between the ages of four and seven years. High levels of dental caries were reported in children of Pacific, Asian, and Maori ethnicity. Food frequency questionnaire information was summarised into two principal components. The major axis of variation was in the intake of food and drinks with high concentrations of sugar and refined starch, with this component strongly associated with caries (multivariable incidence rate ratio of caries 0.48; 95% confidence interval: 0.38-0.61, comparing the extreme quintiles of the first principal component). CONCLUSIONS: A diet high in sugar or refined starch was strongly linked to caries. Policies to reduce sugar and refined starch intake should be considered.

Arsenic in Hair as a Marker of Exposure to Smoke from the Burning of Treated Wood in Domestic Wood Burners.

Timber treated with the anti-fungal chemical copper chrome arsenate is used extensively in the New Zealand building industry. While illegal, the burning of treated timber is commonplace in New Zealand and presents a health risk. Outdoor ambient monitoring of arsenic in airborne particulate matter in New Zealand has identified levels that exceed the maximum standards of 5.5 ng m-3 (annual average) at some urban locations. In this study, two-week-old beard hair samples were collected during the winter months to establish individual exposure to arsenic using Inductively Coupled Plasma-Mass Spectrometry. These results were then compared with questionnaire data about wood burner use for the two weeks prior to sampling, and spatial trends in arsenic from ambient monitoring. Results suggest that the burning of construction timber that may contain arsenic is associated with a higher level of arsenic in hair than those who burn logs or coal exclusively. There is no association between the area-level density of wood burners and arsenic levels but a significant correlation with individual household choice of fuel as well as the smell of wood smoke in the community, suggesting very localised influences. Strategies are needed to raise awareness of the risks of burning treated timber and to provide economically-viable alternatives.

Nutrition guidelines for dental care vs the evidence: is there a disconnect?

Dental caries is the most common chronic childhood disease in New Zealand. Concurrently, obesity and related chronic metabolic diseases are the most challenging public health problems of modern times. There is considerable evidence that a common dietary behaviour-high frequency consumption of sugar- and starch-containing foods-is the principal aetiological factor for both dental caries, and presentation of children and young people with increased adiposity or obesity. Conversely, consumption of full-fat dairy products by children and young people is associated with reduced risks of dental caries and obesity. Government-endorsed dietary guidelines for young people correctly provide recommendations to decrease intake of high-sugar foods. However, recommendations are provided to increase the frequency of consumption of sugar- and starch-containing foods as children age, and to choose low-fat dairy produce. We contend that this advice directly contradicts evidence of the dietary causes of both dental caries and obesity. This advice also does not reflect evidence regarding observed associations between the consumption of full-fat dairy produce and reduced dental caries and obesity. We present evidence to support our contention that important elements of New Zealand's dietary guidelines have been established without due consideration of the entirety of the evidence, including that which is updated, recent or evolutionarily. Given the epidemics of dental caries and metabolic disease are ongoing public health challenges in New Zealand and share common dietary causes, guidelines for healthy eating should limit refined sugar- and starch-containing foods and encourage intake of full-fat dairy items.

I was truly addicted to sugar: A consumer-focused classification system of behaviour change strategies for sugar reduction.

The reduction of free sugars has been identified as a priority issue internationally. A range of public health initiatives have been recommended, including the provision of information and support for sugar reduction. To inform these approaches, it is important to know what people actually do in real world settings to reduce their consumption. This study documents and defines the range of consumer-based behaviour change strategies for sugar reduction. A total of 1145 strategies were extracted from 47 internet sources (i.e., consumer, popular and professional). Using a pragmatic content analysis, hundreds of strategies were organized into 25 discrete categories of strategies. Categories were grouped into the Rubicon Model of Action Phases and classified as pre-decisional (i.e., decisional balance, feedback, realisation, seek knowledge and information), post-decisional (i.e., action planning, coping planning, set goal intention, sugar guidelines) and actional phase. Actional strategies were the most prolific and included avoidance, consumption control, consumption planning, environmental restructuring, healthy eating focus, maintain readiness, professional support, refocusing, self-monitoring, social support, substance substitution, tapering, address underlying issues, urge management, well-being and withdrawal management. There was one post-actional strategy which was associated with self-evaluation (i.e., reviewing a change attempt in order to plan for the future). Four categories of strategies differed according to the source. Substance substitution was substantially less frequently discussed by consumers than professionals and few professional sites acknowledged or advised strategies to manage the struggle of maintaining readiness following a change attempt. Hundreds of individual strategies are discussed or promoted in online settings, and more information is needed on the effectiveness of these self-initiated approaches.

How strong is the relationship between scabies and acute rheumatic fever? An analysis of neighbourhood factors.

AIM: Recent studies have linked scabies with acute rheumatic fever (ARF). We explored the relationship, by neighbourhood, between permethrin dispensing as an indicator of scabies prevalence and ARF cases over the same period. METHODS: Incident cases of ARF notified to public health between September 2015 and June 2018 and the annual incidence of prescribing by neighbourhood over the same period were analysed. Evidence of an association between permethrin and ARF was obtained by carrying out Poisson regression of the rate of ARF in terms of permethrin rate at the census area unit level, with adjustment for ethnicity and socio-economic deprivation. RESULTS: A total of 413 neighbourhoods were included. The incidence of ARF varied between 0 and 102 per 100 000 people per year (mean 4.3). In contrast, the annual incidence of dispensing of permethrin varied between 0 and 3201 per 100 000 people per year (mean 771). A strong association was observed between the two variables. In an adjusted quasi-Poisson model, permethrin-dispensing rates were strongly associated with ARF incidence, with a change from the 16th to the 84th centile associated with a 16.5-fold increase in incidence (95% confidence interval: 3.82-71.6). CONCLUSIONS: Permethrin prescribing as an indicator of scabies is strongly associated with the incidence of ARF. Considered together with other studies, this evidence suggests that improving scabies control may reduce the burden of ARF in New Zealand.

Are Liquid Sugars Different from Solid Sugar in Their Ability to Cause Metabolic Syndrome?

OBJECTIVE: Intake of sugary drinks, especially soft drinks, carries increased risk for obesity and diabetes. This article reviews whether sugary drinks carry different risks for metabolic syndrome compared with foods that contain natural or added sugars. METHODS: A narrative review was performed to evaluate differences between liquid and solid sugars in their ability to induce metabolic syndrome and to discuss potential mechanisms to account for the differences. RESULTS: Epidemiological studies support liquid added sugars, such as soft drinks, as carrying greater risk for development of metabolic syndrome compared with solid sugar. Some studies suggest that fruit juice may also confer relatively higher risk for weight gain and insulin resistance compared with natural fruits. Experimental evidence suggests this may be due to differences in how fructose is metabolized. Fructose induces metabolic disease by reducing the energy levels in liver cells, mediated by the concentration of fructose to which the cells are exposed. The concentration relates to the quantity and speed at which fructose is ingested, absorbed, and metabolized. CONCLUSIONS: Although reduced intake of added sugars (sucrose and high-fructose corn syrup) remains a general recommendation, there is evidence that sugary soft drinks may provide greater health risks relative to sugar-containing foods.

Invasive pneumococcal disease and serotype emergence in the Auckland region during the vaccine era 2009-16.

INTRODUCTION There is a deficit of knowledge in New Zealand as the epidemiology of invasive pneumococcal disease varies significantly between countries. AIM Time trends and sociodemographic characteristics of cases of invasive pneumococcal disease (IPD) in the Auckland region are reviewed after the introduction of a conjugate vaccination, to provide evidence for future vaccine policy and to ensure Auckland region analysis is representative of national trends for subsequent IPD analysis. METHODS Data on all cases of IPD occurring in Waitemata, Auckland and Counties Manukau District Health Boards between 2009 and 2016 were extracted from EpiSurv. Denominator data were drawn from mid-year estimates supplied by Statistics New Zealand. Descriptive epidemiology and time-series regression was performed to analyse trends. RESULTS Rates of IPD have fallen in the Auckland region over the past 8 years by 32%. While absolute rates in the elderly have reduced by 12%, they have the highest disease burden at 32/100,000. The ethnic disparity continues with Pacific people (33/100,000) and Maori (14/100,000) over represented compared to European (10/100,000). In the elderly, the 19A serotype has increased from an incidence of 0 in 2008 to 8.2/100,000. DISCUSSION Large ethnic and age-related disparities are observed in the Auckland region, consistent with the rest of the country, since the start of the pneumococcal vaccination era. Extending immunisation to the elderly may help close these gaps. As with other countries, there is 19A serotype replacement occurring following conjugate vaccine introduction.

How reliable is the statistical evidence for limiting saturated fat intake? A fresh look at the influential Hooper meta-analysis.

BACKGROUND: Evidence from meta-analyses has been influential in deciding whether or not limiting saturated fat intake reduces the incidence of cardiovascular disease. Recently, random effects analyses have been criticised for exaggerating the influence of publication bias and an alternative proposed which obviates this issue: 'inverse-variance heterogeneity'. AIMS: We re-analysed the influential Hooper meta-analysis that supports limiting saturated fat intake to decide whether or not the results of the study were sensitive to the method used. METHODS: Inverse-variance heterogeneity analysis of this summary study was carried out, and the results contrasted with standard methods. Publication bias was also considered. RESULTS: Inverse variance heterogeneity analysis of the Hooper combined cardiovascular disease end point results returned a pooled relative risk of 0.93 (95% confidence interval: 0.74-1.16). This finding contrasts with the traditional random effects analysis with the corresponding statistic of 0.83 (95% confidence interval: 0.72-0.96). Egger tests, funnel and Doi plots along with recently published suppressed trial results suggest that publication bias is present. CONCLUSIONS: This study questions the use of the Hooper study as evidence to support limiting saturated fat intake. Our re-analysis, together with concordant results from other meta-analyses of trials indicate that routine advice to reduce saturated fat intake in people with (or at risk for) cardiovascular disease be reconsidered.

Low-carbohydrate diets differing in carbohydrate restriction improve cardiometabolic and anthropometric markers in healthy adults: A randomised clinical trial.

BACKGROUND: Low-carbohydrate, high-fat (LCHF) diets are useful for treating a range of health conditions, but there is little research evaluating the degree of carbohydrate restriction on outcome measures. This study compares anthropometric and cardiometabolic outcomes between differing carbohydrate-restricted diets. OBJECTIVE: Our hypothesis was that moderate carbohydrate restriction is easier to maintain and more effective for improving cardiometabolic health markers than greater restriction. DESIGN: A total of 77 healthy participants were randomised to a very low-carbohydrate ketogenic diet (VLCKD), low-carbohydrate diet (LCD), or moderate-low carbohydrate diet (MCD), containing 5%, 15% and 25% total energy from carbohydrate, respectively, for 12-weeks. Anthropometric and metabolic health measures were taken at baseline and at 12 weeks. Using ANOVA, both within and between-group outcomes were analysed. RESULTS: Of 77 participants, 39 (51%) completed the study. In these completers overall, significant reductions in weight and body mass index occurred ((mean change) 3.7 kg/m2; 95% confidence limits (CL): 3.8, 1.8), along with increases in high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, (0.49 mmol/L; 95% CL; 0.06, 0.92; p = 0.03), and total cholesterol concentrations (0.11 mmol/L; 95% CL; 0.00, 0.23; p = 0.05). Triglyceride (TG) levels were reduced by 0.12 mmol/L (95% CL; -0.20, 0.02; p = 0.02). No significant changes occurred between groups. The largest improvements in high density lipoprotein cholesterol (HDL-c) and TG and anthropometric changes occurred for the VLCKD group. CONCLUSIONS: Low-carbohydrate, high-fat diets have a positive effect on markers of health. Adherence to the allocation of carbohydrate was more easily achieved in MCD, and LCD groups compared to VLCKD and there were comparable improvements in weight loss and waist circumference and greater improvements in HDL-c and TG with greater carbohydrate restriction.

Effects of differing levels of carbohydrate restriction on mood achievement of nutritional ketosis, and symptoms of carbohydrate withdrawal in healthy adults: A randomized clinical trial.

OBJECTIVES: To our knowledge, minimal research exists on the effects of diets differing in carbohydrate restriction on symptoms of carbohydrate withdrawal and mood, and the achievement of nutritional ketosis (NK). The aim of this study was to compare ketonaemia, symptoms of carbohydrate withdrawal, and mood. We hypothesized that a moderate carbohydrate restriction would result in fewer symptoms and a reduced effect on mood. METHODS: Seventy-seven healthy participants (25 men and 52 women; mean age: 39 y, range: 25-49; mean body mass index 27 kg/m2, range: 20-39) were randomized to receive either a very-low-carbohydrate ketogenic diet (VLCKD), low-carbohydrate diet (LCD), or moderately low-carbohydrate diet (MCD), containing 5%, 15%, and 25% total energy (TE) from carbohydrate, respectively, for 3 wk. Fasting blood ketone measures were recorded daily upon waking along with a data from symptom questionnaire and a 5-point mood-state scale. Using analysis of variance and a 5% two-sided α level to determine statistical significance, between-group outcomes were analyzed. Additional association and analyses were conducted by multiple linear regression. RESULTS: In 75 of 77 initial participants included for analysis, mean serum levels of ß-hydroxybutyrate (ßOHB) were increased by 0.27 ± 0.32, 0.41 ± 0.38, and 0.62 ± 0.49 mmol/L for MCD, LCD, and VLCKD, respectively (P = 0.013). The achievement of NK was consistent for both VLCKD and LCD groups and sporadic for the MCD group. Only the VLCKD group exhibited 95% confidence interval levels that were consistently ≥0.5 mmol/L. The overall mean change in sum of symptoms scores (SOSS) from baseline was 0.81 ± 2.84 (P < 0.001). Changes in SOSS were highest in the VLCKD group (1.49 ± 2.47), followed by LCD (0.65 ± 2.70) and MCD (0.18 ± 3.3; P = 0.264). Small, statistically significant increases were seen for headache severity, constipation, diarrhea, halitosis, muscle cramps and muscle weakness, and light-headedness, whereas intestinal bloating and craving for sugar and starch improved from baseline. Only halitosis (P = 0.039) and muscle weakness (P = 0.005) differed significantly between the groups. Mood improved significantly from baseline overall, but there was no significant difference between groups (P = 0.181) CONCLUSIONS: Diets containing 5% TE from carbohydrates are ketogenic, but diets containing between 15% and 25% TE from carbohydrates can also result in mean ßOHB ≥0.5 mmol/L. There was no meaningful difference in symptoms of carbohydrate withdrawal between diets that contain 5% to 25% TE from carbohydrate, and mood was improved overall, with no significant difference between interventions. Our conclusion, therefore, is that reduced carbohydrate diets should be prescribed by need rather than the desire to mitigate symptoms of carbohydrate withdrawal.