Salt and sugar intakes of adults in the central division of Fiji: findings from a nutrition survey in 2022.

Background: Excess salt and sugar consumption contribute to diseases, such as diabetes and hypertension. This study aimed to estimate salt and sugar intakes and main sources, in a population of adults in the Central Division of Fiji. Methods: One adult per household was randomly selected to participate (n = 700). Sociodemographic characteristics; blood pressure, weight, and height; a 24-h diet recall; and spot-urine samples were collected, with 24-h urine samples from a sub-sample (n = 200). Sugar intake was estimated from the 24-h diet recalls and salt intake from the spot-urines. 24-hr diet recall was used to identify main sources of salt and sugar by food groups. Findings: 534 adults (response rate 76%, 50% women, mean age 42 years) participated. Salt intake was 8.8 g/day (95% CI, 8.7-9.0), and free sugar intake was 74.1 g/day (67.5-80.7), 16.1% of total energy intake (15.0-17.1%). Main sources of salt were mixed cooked dishes (40.9% (38.2-43.5)), and bread and bakery products (28.7% (26.5-31.0)). Main sources of sugar were table sugars, honey, and related products (24.3% (21.7-26.8)), non-alcoholic beverages (21.4% (18.8-24.0)) and bread and bakery products (18.0% (16.2-19.9)). Interpretation: Salt and sugar intakes exceeded World Health Organization recommendations in this sample of adults. Given dietary sources were foods high in salt and sugar, along with the addition to food or drinks, interventions focused on behavior along with environmental strategies to encourage healthier choices are needed. Funding: NHMRC and GACD grant APP1169322.

Addressing the global obesity burden: a gender-responsive approach to changing food environments is needed.

Obesity is a leading cause of death and disability globally. There is a higher proportion of women living with obesity than men, with differences in prevalence rates between women and men particularly staggering in low- and middle-income countries. The food environments that most people live in have been defined as 'obesogenic', characterised by easy access to energy dense, highly palatable foods with poor nutritional value. There is an established need to intervene to change food environments to prevent obesity. However, minimal successes are evident with no country set to meet the WHO goal of reducing obesity prevalence to 2010 numbers by 2025. In this review, we provide a narrative around the sex (biological)- and gender (sociocultural)-related considerations for the relationship between nutrition, interactions with the food environment and obesity risk. We provide an argument that there are gendered responses to food environments that place women at a higher risk of obesity particularly in relation to food industry influences, due to gendered roles and responsibilities in relation to paid and unpaid labour, and due to specific food security threats. This review concludes with hypotheses for addressing the obesity burden in a gender-responsive manner, with a call for gender equity to be a key component of the development, implementation and monitoring of obesity prevention focused policies going forward.

Strengthening national salt reduction strategies using multiple methods process evaluations: case studies from Malaysia and Mongolia.

OBJECTIVE: To understand the extent to which national salt reduction strategies in Malaysia and Mongolia were implemented and achieving their intended outcomes. DESIGN: Multiple methods process evaluations conducted at the mid-point of strategy implementation, guided by theoretical frameworks. SETTING: Malaysia (2018-2019) and Mongolia (2020-2021). PARTICIPANTS: Desk-based reviews of related documents, interviews with key stakeholders (n 12 Malaysia, n 10 Mongolia), focus group discussions with health professionals in Malaysia (n 43) and health provider surveys in Mongolia (n 12). RESULTS: Both countries generated high-quality local evidence about salt intake and levels in foods and culturally specific education resources. In Malaysia, education and reformulation activities were delivered with moderate dose (quantity) but reach among the population was low. Within 5 years, Mongolia implemented education among schools, health professionals and food producers on salt reduction with high reach, but with moderate dose (quantity) and reach among the general population. Both countries faced challenges in implementing legislative interventions (mandatory salt labelling and salt limits in packaged foods) and both could improve the scaling up of their reformulation and education activities. CONCLUSIONS: In the first half of Malaysia's and Mongolia's strategies, both countries generated necessary evidence and education materials, mobilised health professionals to deliver salt reduction education and achieved small-scale reformulation in foods. Both subsequently should focus on implementing regulatory policies and achieving population-wide reach and impact. Process evaluations of existing salt reduction strategies can help strengthen intervention delivery, aiding achievement of WHO's 30 % reduction in salt intake by 2025 target.

Food insecurity, COVID-19 and diets in Fiji - a cross-sectional survey of over 500 adults.

INTRODUCTION: Food insecurity is associated with inadequate nutrition and increased rates of chronic disease. The primary aim of this study was to assess self-reported food insecurity and the perceived impact of COVID-19 on food security, in two regional districts of Central Fiji, as part of a broader program of work on strengthening and monitoring food policy interventions. The secondary aim was to explore the relationship between food insecurity and salt, sugar and fruit and vegetable intake. METHODS: Seven hundred adults were randomly sampled from the Deuba and Waidamudamu districts of Viti Levu, Fiji. Interview administered surveys were conducted by trained research assistants with data collected electronically. Information was collected on demographics and health status, food security, the perceived impact of COVID-19 on food security, and dietary intake. Food insecurity was assessed using nine questions adapted from Fiji's 2014/5 national nutrition survey, measuring markers of food insecurity over the last 12 months. Additional questions were added to assess the perceived effect of COVID-19 on responses. To address the secondary aim, interview administered 24-hour diet recalls were conducted using Intake24 (a computerised dietary recall system) allowing the calculation of salt, sugar and fruit and vegetable intakes for each person. Weighted linear regression models were used to determine the relationship between food insecurity and salt, sugar and fruit and vegetable intake. RESULTS: 534 people participated in the survey (response rate 76%, 50.4% female, mean age 42 years). 75% (75.3%, 95% CI, 71.4 to 78.8%) of people reported experiencing food insecurity in the 12 months prior to the survey. Around one fifth of people reported running out of foods (16.8%, 13.9 to 20.2%), having to skip meals (19.3%, 16.2 to 22.9%), limiting variety of foods (19.0%, 15.9 to 22.5%), or feeling stressed due to lack of ability to meet food needs (19.5%, 16.4 to 23.0%). 67% (66.9%, 62.9 to 70.7%) reported becoming more food insecure and changing what they ate due to COVID-19. However, people also reported positive changes such as making a home garden (67.8%, 63.7 to 71.6%), growing fruit and vegetables (59.5%, 55.6 to 63.8%), or trying to eat healthier (14.7%, 12.0 to 18.0%). There were no significant associations between food insecurity and intakes of salt, sugar or fruit and vegetables. CONCLUSION: Participants reported high levels of food insecurity, exceeding recommendations for salt and sugar intake and not meeting fruit and vegetable recommendations, and becoming more food insecure due to COVID-19. Most participants reported making home gardens and/or growing fruit and vegetables in response to the pandemic. There is an opportunity for these activities to be fostered in addressing food insecurity in Fiji, with likely relevance to the Pacific region and other Small Island Developing States who face similar food insecurity challenges.

The nutritional profile of plant-based meat analogues available for sale in Australia.

AIM: To assess the nutritional quality of plant-based meat analogues in Australia, compared to equivalent meat products, and to assess levels of micronutrient fortification in meat analogues. METHODS: This cross-sectional study used nutrition composition data for products collected in 2021 from major supermarkets in Australia. Nutritional quality was assessed using the Health Star Rating, energy (kJ), protein (g), saturated fat (g), sodium (mg), total sugars (g), and fibre content (g) per 100 g, and level of food processing using the NOVA classification. Proportion of products fortified with iron, vitamin B12 and zinc were reported. Differences in health star rating and nutrients between food categories were assessed using independent t-tests. RESULTS: Seven hundred ninety products (n = 132 plant-based and n = 658 meat) across eight food categories were analysed. Meat analogues had a higher health star rating (mean 1.2 stars, [95% CI: 1.0-1.4 stars], p < 0.001), lower mean saturated fat (-2.4 g/100 g, [-2.9 to -1.8 g/100 g], p < 0.001) and sodium content (-132 mg/100 g, [-186 to -79 mg/100 g], p < 0.001), but higher total sugar content (0.7 g/100 g, [0.4-1.1 g/100 g], p < 0.001). Meat analogues and meat products had a similar proportion of ultra-processed products (84% and 89%, respectively). 12.1% of meat analogues were fortified with iron, vitamin B12 and zinc. CONCLUSION: Meat analogues generally had a higher health star rating compared with meat equivalents, however, the nutrient content varied. Most meat analogues were also ultra-processed and few are fortified with key micronutrients found in meat. More research is needed to understand the health impact of these foods.

Incorporating a gender lens into nutrition and health-related policies in Fiji: analysis of policies and stakeholder perspectives.

BACKGROUND: Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. METHODS: This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. RESULTS: Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. CONCLUSIONS: There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji.

Research protocol for impact assessment of a project to scale up food policies in the Pacific.

BACKGROUND: One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji. METHODS: To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost-consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact. DISCUSSION: By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

Strengthening implementation of diet-related non-communicable disease prevention strategies in Fiji: a qualitative policy landscape analysis.

BACKGROUND: Noncommunicable diseases (NCDs) are the leading cause of death globally, and the World Health Organization (WHO) has recommended a comprehensive policy package for their prevention and control. However, implementing robust, best-practice policies remains a global challenge. In Fiji, despite political commitment to reducing the health and economic costs of NCDs, prevalence of diabetes and cardiovascular disease remain the highest in the region. The objective of this study was to describe the political and policy context for preventing diet-related NCDs in Fiji and policy alignment with WHO recommendations and global targets. We used a case study methodology and conducted (1) semi-structured key informant interviews with stakeholders relevant to diet-related NCD policy in Fiji (n = 18), (2) documentary policy analysis using policy theoretical frameworks (n = 11), (3) documentary stakeholder analysis (n = 7), and (4) corporate political activity analysis of Fiji's food and beverage industry (n = 12). Data were sourced through publicly available documents on government websites, internet searches and via in-country colleagues and analysed thematically. RESULTS: Opportunities to strengthen and scale-up NCD policies in Fiji in line with WHO recommendations included (1) strengthening multisectoral policy engagement, (2) ensuring a nutrition- and health-in-all policy approach, (3) using a whole-of-society approach to tighten political action across sectors, and (4) identifying and countering food industry influence. CONCLUSION: Diet-related NCD policy in Fiji will be strengthened with clearly defined partner roles, responsibilities and accountability mechanisms, clear budget allocation and strong institutional governance structures that can support and counter industry influence. Such initiatives will be needed to reduce the NCD burden in Fiji.

Gender roles, generational changes and environmental challenges: an intersectional interpretation of perceptions on healthy diets among iTaukei women and men in Fiji.

OBJECTIVE: To investigate perceptions of iTaukei Fijian women and men around diet and the ability to consume a healthy diet. DESIGN: Six focus groups were conducted with women and men separately. Six to ten women and men participated in each group. Discussions were recorded, transcribed, translated and thematically analysed. Themes were mapped to an intersectionality framework to aid interpretation. SETTING: Four villages in Viti Levu, Fiji. PARTICIPANTS: Twenty-two women and twenty-four men. RESULTS: Seven overarching themes were identified, including generational changes in food behaviour, strong-gendered beliefs around food and food provision, cultural and religious obligations around food, the impact of environmental change on the ability to consume a healthy diet, perceptions of the importance of food, food preferences and knowledge. Participants across focus groups identified that it was the 'duty' of women to prepare food for their families. However, some women reflected on this responsibility being unbalanced with many women now in the formal workforce. Changes between generations in food preferences and practices were highlighted, with a perception that previous generations were healthier. Power dynamics and external factors, such as environmental changes, were identified by women and men as crucial influences on their ability to eat a healthy diet. CONCLUSION: Embedded traditional perceptions of gendered roles related to nutrition were misaligned with other societal and environmental changes. Given factors other than gender, such as broader power dynamics and environmental factors were identified as influencing diet, viewing nutrition-related issues through an intersectional lens is important to inform equitable food policy in Fiji.

Contextualising sex and gender research to improve women's health: An early- and mid-career researcher perspective.

The field of sex and gender research in health and medicine is growing, and many early- and mid-career researchers (EMCRs) are developing skills in this area. As EMCRs specialising in sex and gender research, we aim to better understand sex- and gender-based determinants of human health, challenge long-standing and pervasive gender biases, and contribute to improving the evidence base upon which clinical guidelines and policy interventions are developed. To effectively achieve these goals, we believe that EMCRs would benefit from understanding the challenges of working in this space and participate in driving change in three key areas. First, in creating greater links between the goals of sex and gender research and addressing systemic bias against women and gender minorities, to effectively translate knowledge about sex and gender differences into improved health outcomes. Second, in expanding the reach of sex and gender research to address women's health in an intersectional way and ensure that it also benefits the health of men, transgender and gender-diverse people and those who are intersex. Third, in working with others in the scientific community to improve methods for sex and gender research, including updating data collection practises, ensuring appropriate statistical analyses and shifting scientific culture to recognise the importance of null findings. By improving focus on these three areas, we see greater potential to translate this research to improve women's health and reduce health inequities for all.

The tide of dietary risks for noncommunicable diseases in Pacific Islands: an analysis of population NCD surveys.

OBJECTIVE: To describe changes over time in dietary risk factor prevalence and non-communicable disease in Pacific Island Countries (PICTs). METHODS: Secondary analysis of data from 21,433 adults aged 25-69, who participated in nationally representative World Health Organization STEPs surveys in 8 Pacific Island Countries and Territories between 2002 and 2019. Outcomes of interest were changes in consumption of fruit and vegetables, hypertension, overweight and obesity, and hypercholesterolaemia over time. Also, salt intake and sugar sweetened beverage consumption for those countries that measured these. RESULTS: Over time, the proportion of adults consuming less than five serves of fruit and vegetables per day decreased in five countries, notably Tonga. From the most recent surveys, average daily intake of sugary drinks was high in Kiribati (3.7 serves), Nauru (4.1) and Tokelau (4.0) and low in the Solomon Islands (0.4). Average daily salt intake was twice that recommended by WHO in Tokelau (10.1 g) and Wallis and Futuna (10.2 g). Prevalence of overweight/obesity did not change over time in most countries but increased in Fiji and Tokelau. Hypertension prevalence increased in 6 of 8 countries. The prevalence of hypercholesterolaemia decreased in the Cook Islands and Kiribati and increased in the Solomon Islands and Tokelau. CONCLUSIONS: While some Pacific countries experienced reductions in diet related NCD risk factors over time, most did not. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia. Population-wide approaches to promote fruit and vegetable consumption and reduce sugar, salt and fat intake need strengthening.

Understanding Enablers and Barriers to the Implementation of Nutrition Standards in Publicly Funded Institutions in Victoria.

Effective implementation of nutrition standards in publicly funded institutions can facilitate healthy food and beverage consumption by communities and populations, which can enable improvements in dietary intake and reduce disease burden. This study aimed to understand stakeholder perspectives on the implementation of government nutrition standards in publicly funded institutions in the Australian state of Victoria, as well as to determine enablers and barriers to successful implementation. Pre-interview questionnaires and semi-structured interviews were administered to stakeholders involved in the implementation of nutrition standards in publicly funded institutions in Victoria. The Interactive Systems Framework, which allows understanding of the infrastructure and systems needed to implement policies, was used to design the survey instruments and guide the data analysis. Forty-four stakeholders were interviewed, including program implementers, support personnel and food providers, across public sector hospitals and health services, workplaces, sport and recreation centres and schools. Though translated materials and resources have been developed for end-users to facilitate uptake and implementation, current nutrition standards were perceived to be long and complex, which hindered implementation. The existence of a government-funded implementation support service enabled action by providing technical support, troubleshooting and capacity-building. A specific pathway for successful guideline implementation was determined through the analysis. Opportunities to close the policy-implementation gap were identified. This will be crucial to maximising the impact of nutrition standards on population diets and reducing diet-related disease. Strengthening the guidelines and their governance, streamlining the support system and overcoming barriers within and outside of implementing organisations, are urgently required to propel statewide progress.

Strengthening Sugar-Sweetened Beverage Taxation for Non-Communicable Disease Prevention: A Comparative Political Economy Analysis Case Study of Fiji and Tonga.

Diet-related fiscal policy is an effective NCD prevention strategy. However, current sugar-sweetened beverage (SSB) taxes in Fiji and Tonga have not had the desired effect; SSB consumption in Fiji, for example, contributes to mortality more than double the global rates and is highest in the WHO Western Pacific Region. We therefore aimed to better understand the perceived underlying political economy drivers that have and continue to affect change in each country. Our study design utilised a comparative case study that triangulated documentary policy and stakeholder analysis with semi-structured stakeholder interviews in both countries and an in-depth corporate political activity analysis in Fiji. We drew on theoretical frameworks relevant to political economy to collect and analyse policy and stakeholder data, and utilised established corporate political activity frameworks to analyse industry activity. Common findings to both Fiji and Tonga suggested that the SSB tax impact could be increased through multisectoral engagement, embracing a whole-of-society approach, strengthened institutional structures and leveraging off competing priorities across sectors towards more common goals. These findings provide opportunities and lessons for Fiji and Tonga as well as other similar settings seeking to strengthen or upscale the impact of diet-related fiscal policy.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation.

BACKGROUND: There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS: Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION: The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

A review of front-of-pack nutrition labelling in Southeast Asia: Industry interference, lessons learned, and future directions.

Front-of-pack nutrition labelling is an evidence-based nutrition intervention that is recommended by the World Health Organization and other health agencies as an effective non-communicable disease prevention strategy. To date, the types of front-of-pack labels that have been identified as being most effective have yet to be implemented in Southeast Asia. This has been partly attributed to extensive industry interference in nutrition policy development and implementation. This paper outlines the current state of food labelling policy in the region, describes observed industry interference tactics, and provides recommendations for how governments in Southeast Asia can address this interference to deliver best-practice nutrition labelling to improve diets at the population level. The experiences of four focal countries - Malaysia, Thailand, the Philippines, and Viet Nam - are highlighted to provide insights into the range of industry tactics that are serving to prevent optimal food labelling policies from being developed and implemented. Funding: This research was supported by the United Kingdom Global Better Health Programme, which is managed by the United Kingdom Foreign, Commonwealth and Development Office and supported by PricewaterhouseCoopers in Southeast Asia.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam.

OBJECTIVE: To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC). DESIGN: Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy. SETTING: Argentina, Mongolia, South Africa and Vietnam. PARTICIPANTS: Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes. RESULTS: Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts. CONCLUSIONS: Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

The association of energy and macronutrient intake with all-cause mortality, cardiovascular disease and dementia: findings from 120 963 women and men in the UK Biobank.

This study aimed to investigate the association between individual and combinations of macronutrients with premature death, CVD and dementia. Sex differences were investigated. Data were utilised from a prospective cohort of 120 963 individuals (57 % women) within the UK Biobank, who completed ≥ two 24-h diet recalls. The associations of macronutrients, as percentages of total energy intake, with outcomes were investigated. Combinations of macronutrients were defined using k-means cluster analysis, with clusters explored in association with outcomes. There was a higher risk of death with high carbohydrate intake (hazard ratios (HR), 95 % CI upper v. lowest third 1·13 (1·03, 1·23)), yet a lower risk with higher intakes of protein (upper v. lowest third 0·82 (0·76, 0·89)). There was a lower risk of CVD with moderate intakes (middle v. lowest third) of energy and protein (sub distribution HR (SHR), 0·87 (0·79, 0·97) and 0·87 (0·79, 0·96), respectively). There was a lower risk of dementia with moderate energy intake (SHR 0·71 (0·52, 0·96)). Sex differences were identified. The dietary cluster characterised by low carbohydrate, low fat and high protein was associated with a lower risk of death (HR 0·84 (0·76, 0·93)) compared with the reference cluster and a lower risk of CVD for men (SHR 0·83 (0·71, 0·97)). Given that associations were evident, both as single macronutrients and for combinations with other macronutrients for death, and for CVD in men, we suggest that the biggest benefit from diet-related policy and interventions will be when combinations of macronutrients are targeted.

Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs). RECENT FINDINGS: The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures-salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure-were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country's income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.

Packaged food supply in Fiji: nutrient levels, compliance with sodium targets and adherence to labelling regulations.

OBJECTIVE: To estimate the proportion of products meeting Fiji government labelling regulations, assess compliance with national Na reformulation targets and examine the Na and total sugar levels in packaged foods sold in selected major supermarkets. DESIGN: We selected five major supermarkets in 2018 and collected the product information and nutritional content from the labels of all packaged foods sold. We organised 4278 foods into fourteen major food categories and thirty-six sub-categories and recorded the proportion of products labelled in accordance with the Fiji labelling regulations. We looked at the levels of Na and total sugar in each food category and assessed how many products complied with the Fiji reformulation targets set for Na. We also listed the companies responsible for each product. SETTING: Suva, Fiji. RESULTS: Fourteen percentage of packaged foods in fourteen major categories met Fiji national labelling regulations. Na was labelled on 95·4 % products, and total sugar labelled on 92·4 %. The convenience foods category had the highest Na levels (1699 mg/100 g), while confectionery had the highest content of total sugar (52·6 g/100 g). Forty percentage of eligible products did not meet the proposed voluntary Na reformulation targets. CONCLUSIONS: Our findings indicate significant room for improvement in nutrient labelling, as well as a need for further enforcement of reformulation targets and monitoring of changes in food composition. Through enacting these measures and establishing additional regulations such as mandatory front-of-pack labelling, government and food industry can drive consumers towards healthier food choices and improve the nutritional quality of packaged foods in Fiji.

Stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership: a qualitative study.

BACKGROUND: Interventions to reduce population salt intake are feasible and cost-effective. The Victorian Salt Reduction Partnership implemented a complex, multi-faceted salt reduction intervention between 2014 and 2020 in the Australian state of Victoria. This study aimed to understand stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership. METHODS: Semi-structured interviews were conducted with Partnership and food industry stakeholders. The Consolidated Framework for Implementation Research was adapted for the Partnership intervention and used to guide the qualitative analysis. RESULTS: Fourteen Partnership and seven food industry stakeholders were interviewed. The Partnership was viewed as essential for intervention planning and decision-making and an enabler for intervention delivery. The goals of capacity building and collaborative action were perceived to have been achieved. The implementation team executed intended intervention activities and outputs, with some adaptations to strategy. Barriers and enablers to implementation were identified by interviewees, such as compatibility of individual, organisational and Partnership values and building positive relationships between the Partnership and food industry, respectively. Legal, political, social, environmental, technological and economic factors affecting intervention design, delivery and outcomes were identified. CONCLUSIONS: Establishing a Partnership with diverse skills and experience facilitated collaborative action, capacity building and execution of the intervention. Monitoring and evaluating implementation informed strategy adaptations, which allowed optimisation of Partnership strategy. The importance of developing strong communication networks between strategic and implementation-levels was a key lesson.