Use of online food retail platforms throughout the COVID-19 pandemic and associated diet-related chronic disease risk factors: A systematic review of emerging evidence.

Food accessibility was considerably impacted by restrictions during the coronavirus disease 2019 (COVID-19) pandemic, leading to growth in the online food retail sector, which offered contact-free delivery. This systematic review aimed to assess the change in use of online food retail platforms during COVID-19. The secondary aim was to identify diet-related chronic disease risk factors including dietary intake, eating behaviors, and/or weight status associated with the use of online food retail platforms during the pandemic. The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022320498) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Nine electronic databases were searched between January 2020 and October 2023. Studies that reported the frequency or change in use of online groceries, meal delivery applications, and/or meal-kit delivery services before and during the pandemic were included. A total of 53 studies were identified, including 46 cross-sectional studies, 4 qualitative studies, 2 longitudinal cohort studies, and 1 mixed-methods study. Overall, 96% (43/45) of outcomes showed an increase in the use of online groceries during COVID-19, while 55% (22/40) of outcomes showed a decrease in meal delivery applications. Eight of nine outcomes associated the use of online food retail with weight gain and emotional eating. Further research is needed to investigate the links between online food retail and obesity.

Engaging adolescents in chronic disease prevention research: insights from researchers about establishing and facilitating a youth advisory group.

Our comment discusses our experience establishing a youth advisory group focused on chronic disease prevention research. The comment highlights three key learnings: the need for researchers to adapt their working style, the importance of redefining the power dynamics, and disrupting traditional research structures to align with co-researcher engagement models.

In this comment, we share our insights from working with a youth advisory group in adolescent health research. Our comment supports our research paper on co-designing an online health study, "Health4Me." The youth advisors worked with us for a year, during which we also studied leadership and other outcomes.Adolescent health is gaining worldwide attention. Health researchers see the value of working with young people on issues that affect them. To address this need, we formed the Health Advisory Panel for Youth at the University of Sydney. We motivated young people through building new skills and leadership training, rather than only focusing on improved health outcomes or health knowledge.Here are our key lessons as researchers: Flexibility: We changed our approach to support online teamwork with young people, offered payment and worked around their schedules. Changing power dynamics: We empowered young people by engaging them in decisions and involved them in co-authoring papers and presentations. Challenging traditional structures: To support youth- as co-researchers, we used existing sources of funding and offered mentoring. In conclusion, we highlight practical ways of working with a youth advisory group in health research. Our teamwork led to a youth digital health program, published essays, and future research ideas. It is important for researchers to actively involve and support young people in shaping research that affects them.

The evaluation of the Plan-Do-Study-Act cycles for a healthcare quality improvement intervention in primary care.

BACKGROUND: The Plan-Do-Study-Act (PDSA) cycle is an iterative framework that has been gaining traction in primary care for quality improvement. However, its implementation remains understudied. This study evaluated the completion, achievement of goal, content quality, and enablers and barriers associated with completion of high-quality PDSA cycles in cardiovascular disease management in general practices. METHODS: This study analysed data from intervention practices of the QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living people with coronary heart disease (QUEL) study. Content quality of cycles was assessed using a scoring system created based on established criteria of ideal PDSA cycles in the healthcare context. Practice-level factors associated with completion and cycles achieving the planned goal were explored through logistic regression models, and with content quality score through linear regression model. Enablers and barriers were assessed using thematic analysis of practices' responses to the PDSA sections. RESULTS: Ninety-seven cycles were reported by 18/26 (69%) practices. Seventy-seven percent of the cycles were completed and 68% achieved the planned goal. Content quality was low, with a median score of 56% (interquartile interval: 44%, 67%). Odds of cycles that were completed and achieved what was planned increased by 3.6- and 9.6-fold, respectively, with more general practitioners (GPs) within practices. Content quality was higher by 15% with more GPs. Lack of interprofessional engagement was a barrier to implementation. CONCLUSIONS: Cycles were well completed, but poor in content quality, with high variability between practices. Human or capital resources and organisational support may be critical for the completion and cycles achieving the planned goals.

Integrated Text Messaging (ITM) for people attending cardiac and pulmonary rehabilitation: A multicentre randomised controlled trial.

BACKGROUND: People living with cardiac and respiratory disease require improved post-hospital support that is readily available and efficient. OBJECTIVES: To 1) test the effectiveness of an automated, semi-personalised text message support program on clinical and lifestyle outcomes amongst people attending cardiac and pulmonary rehabilitation. Also, 2) to evaluate the program's acceptability and utility using patient-reported outcome and experience measures. METHODS: Multicentre randomised controlled trial (3:1, intervention:control) amongst cardiac and pulmonary rehabilitation attendees. Control received usual care (no message program). Intervention also received a 6-month text message lifestyle and support program. Primary outcome was 6-minute walk distance (6MWD). Secondary outcomes included clinical measures, lifestyle, patient-reported outcome and experience measures, medication adherence and rehabilitation attendance. RESULTS: A total of 316 participants were recruited. They had a mean age of 66.7 (SD 10.1) years. Sixty percent were male (190/316) and 156 were cardiac rehabilitation participants. The cohort's mean baseline 6MWD was higher in the intervention than the control group. At 6 months, 6MWD improved in both groups; it was significantly greater amongst intervention than control participants (unadjusted mean difference of 43.4 m, 95 % CI 4.3 to 82.4; P = 0.0296). After adjustment for baseline values, there was no significant difference between intervention and control groups for 6MWD (adjusted mean difference 2.2 m, -21.2 to 25.6; P = 0·85), medication adherence, or cardiovascular risk factors. At 6-month follow-up, intervention participants reported significantly lower depression scores (adjusted mean difference -1.3, 95 % CI -2.2 to -0.3; P = 0.0124) and CAT scores (adjusted mean difference -3.9, 95 % CI -6.6 to -1.3; P = 0.0038), and significantly lower anxiety (adjusted mean difference -1.1, 95 %CI -2.1 to 0; P = 0.0456). Most participants (86 %) read most of their messages and strongly/agreed that the intervention was easy to understand (99 %) and useful (86 %). CONCLUSIONS: An educational and supportive text message program for cardiac and pulmonary rehabilitation attendees improved anxiety and depression plus program attendance. The program was acceptable to, and useful for, participants and would be suitable for implementation alongside rehabilitation programs. TRIAL REGISTRATION NUMBER: ACTRN12616001167459.

Striking the right balance: co-designing the Health4Me healthy lifestyle digital health intervention with adolescents.

BACKGROUND: Adolescents are navigating a period of rapid growth and development within an era of digitalization. Mobile phone ownership among adolescents is nearly ubiquitous, and this provides an opportunity to harness text messaging to promote a healthy lifestyle and reduce chronic disease risk factors. Inclusion of adolescents throughout the design process has been recognized as essential for engagement and future implementation of such interventions. This study aimed to co-design a bank of text messages to promote a healthy lifestyle which are useful, acceptable, and engaging for adolescents aged 12-18 years old. METHODS: Iterative, mixed-methods design with consumer partnership. Co-design occurred over three stages: text message development, text message review and final refinement and testing. The text message development included literature searches and consumer partnership with an established youth advisory group (n = 16). Participants who gave e-consent participated in text message review. Demographic characteristics were collected, and quantitative surveys were distributed to adolescents (n = up to 50) and health professionals (n = up to 30), who rated text message content for understanding, usefulness and appropriateness (total score out of 15). Final refinement was completed by the research team to edit or remove messages which had low scores and to assess readability and interactivity of the text messages. RESULTS: The Heath Advisory Panel for Youth at the University of Sydney (HAPYUS) identified the top six lifestyle health issues for young people today in relation to chronic disease prevention, which became the key content areas for the text message bank and drafted new text messages. Following text message development, 218 messages were available for review. Adolescents (n = 18, mean age 16.3 [SD 1.4]) and healthcare professionals (n = 16) reviewed the text messages. On average, all reviewers found that the text messages were easy to understand (mean = 13.4/15) and useful (mean = 12.7/15). Based on scoring and open ended-feedback, 91 text messages were edited and 42 deleted. The final text message bank included 131 text messages. The overall program is suitable for a seventh-grade reading level, and interactive. CONCLUSIONS: This study describes the process of effectively engaging adolescents to co-design a text message bank intervention, which are useful, acceptable and engaging for an adolescent audience. The effectiveness of the co-designed text message bank is currently being tested in the Health4Me RCT.

Today's adolescents are growing and developing through a period of increased technology use. Most adolescents have access to a mobile phone which can be used to deliver healthy lifestyle information to them through text messages. However, it is important that researchers engage with adolescents as collaborators to develop any information which may be sent to them, to ensure that it is acceptable and engaging. We aimed to co-design a bank of text messages to promote a healthy lifestyle which are useful, acceptable and engaging for adolescents 12­18 years old. We engaged with 16 adolescents from an established youth advisory group who advised on top health issues they face today in terms of leading a healthy lifestyle, which became key content areas for the text message program. They also drafted text messages around these content areas (218 total). Next, the text messages underwent review with 34 adolescents and healthcare professionals to ensure they were useful, easy to understand and appropriate. After the review, the research team edited, deleted and replaced text messages which did not score well. This resulted in a text message bank to promote a healthy lifestyle with 131 text messages which were useful, acceptable and engaging for adolescents 12­18 years old.

Evaluating the effect of a 12-month youth advisory group on adolescent's leadership skills and perceptions related to chronic disease prevention research: a mixed-methods study.

BACKGROUND: Youth Advisory Groups (YAGs) represent a promising method to engage adolescents in research of relevance to them and their peers. However, YAGs are rarely implemented or evaluated in chronic disease prevention research. The aims of this study were firstly, to evaluate the effect of participation in a 12-month YAG on adolescents' leadership skills and perceptions related to chronic disease prevention research and secondly, to evaluate the process of establishing and facilitating a 12-month YAG and identify barriers and enablers to establishment and facilitation. METHODS: This study was a 12-month pre-post study. Eligible participants were adolescents (13-18-years) and current members of an established YAG. Data collection involved online surveys and semi-structured interviews at baseline, six-months and 12-months follow-up. Participatory outcomes such as self-efficacy, leadership skills, and collective participation were derived from Youth Participatory Action Research Principles (YPAR), and the Lansdown-UNICEF conceptual framework for measuring outcomes of adolescent participation. Process evaluation data were captured via meeting minutes, Slack metrics and researcher logs. Quantitative data was analysed using descriptive statistics and qualitative data was thematically analysed using a reflexive thematic analysis approach. RESULTS: Thirteen (13/16) YAG youth advisors consented to participate in the evaluation study (mean age 16.0 years, SD 1.3; 62% (8/13) identified as female). Survey data assessing participatory outcomes found an increase in leadership and life skills scores over 12-months (+ 8.90 points). Semi-structured interview data collected over the 12-month term revealed three key themes namely: influence, empowerment, and contribution. Comparison of pre-post themes determined a positive trend at follow-ups, demonstrating improved participatory outcomes. Process indicators revealed that at 12-month follow-up the YAG was implemented as planned. Semi-structured interview data determined barriers to YAG facilitation included time and limited face-to-face components, while enablers to YAG facilitation included flexibility, accessible delivery methods, and a supportive adult facilitator. CONCLUSION: This study found that a YAG fostered positive participatory outcomes and unique opportunities for youth participants. A successful YAG based on YPAR principles requires researchers to ensure YAG establishment and facilitation is an iterative process. Taking into consideration important barriers and enablers to YAG facilitation ensures adolescent engagement in a YAG is both meaningful and impactful.

A National Health and Wellness SMS Text Message Program for Breast Cancer Survivors During COVID-19 (EMPOWER-SMS COVID-19): Mixed Methods Evaluation Using the RE-AIM Framework.

BACKGROUND: COVID-19 lockdowns caused widespread closures of supportive care services for breast cancer survivors in Australia. In a randomized controlled trial, our team's lifestyle-focused, evidence-based SMS text message support program (EMPOWER-SMS COVID-19) was found to be acceptable and useful for breast cancer survivors, and it was ready for rapid widespread delivery. OBJECTIVE: This study aims to evaluate the reach (uptake) of an adapted 3-month lifestyle-focused SMS text message program (EMPOWER-SMS COVID-19) and barriers and enablers to implementation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. METHODS: A mixed methods pre-post study was conducted to evaluate the EMPOWER-SMS COVID-19 program. The study evaluated the following aspects: (1) reach/representativeness, which refers to the proportion of participant enrollment (ie, number enrolled/number that visited the study website) and demographics (eg, age, sex, ethnicity, time since completing treatment, Index of Relative Socio-economic Advantage and Disadvantage [IRSAD; quintile 1, which refers to most disadvantaged areas, to quintile 5, which refers to least disadvantaged areas, and remoteness); (2) effectiveness, in which participant engagement and acceptability were evaluated using SMS text message reply data and a feedback survey (5-point Likert scale and free-text responses); (3) adoption, which corresponds to the proportion of organizations or health professionals who agreed to promote the program; (4) implementation fidelity and maintenance, which evaluated SMS text message delivery data, opt-outs, costs, and adaptations. Quantitative data were summarized using means and SDs or frequencies and percentages, while qualitative data were analyzed thematically. RESULTS: With regard to the reach/representativeness of the program, 841/1340 (62.8%) participants enrolled and provided electronic consent. Participants had a mean age of 58.8 (SD 9.8; range 30-87) years. According to the data collected, most participants identified as female (837/840, 99.6%) and White (736/840, 87.6%) and nearly half (418/841, 49.7%) finished treatment ≤18 months ago. Most resided in major cities (574/838, 68.5%) and 30% (251/838) in IRSAD quintile 1 or 2. In terms of effectiveness, 852 replies were received from 511 unique participants (median 1; range 1-26). The most common replies were participants stating how they heard about the program (467/852, 54.8%) or "thank you" (131/852, 15.4%). None of the replies contained urgent safety concerns. Among participants who provided feedback (449/841, 53.4%), most "(strongly) agreed" the SMS text messages were easy to understand (445/448, 99.3%), useful (373/440, 84.8%), helped participants feel supported (388/448, 86.6%), and motivated participants to be physically active (312/445, 70.1%) and eat healthier (313/457, 68.5%). Free-text responses revealed 5 factors influencing engagement: (1) feeling supported and less alone, (2) motivation and reassurance for health self-management, (3) the variety of information, (4) weblinks to information and resources, and (5) the option to save the SMS text messages. Concerning adoption, 50% (18/36) of organizations/health professionals agreed to promote the program. With regard to implementation/maintenance, SMS text messages were delivered as planned (97.43% [41,257/42,344] of SMS text messages were successfully delivered) with minimal opt-outs (62/838, 7.4%) and low cost (Aus $15.40/participant; Aus $1=US $0.67). No adaptations were made during the intervention period. Postintervention adaptations included adding weblinks and participant-selected customizations. CONCLUSIONS: EMPOWER-SMS COVID-19 was implemented quickly, had a broad reach, and had high engagement and acceptability among socioeconomically diverse participants. The program had high fidelity, low cost, and required minimal staff oversight, which may facilitate future implementation. However, further research is needed to evaluate barriers and enablers to adoption and implementation for health professionals and strategies for long-term maintenance.

Feasibility and Acceptability of Chatbots for Nutrition and Physical Activity Health Promotion Among Adolescents: Systematic Scoping Review With Adolescent Consultation.

BACKGROUND: Reducing lifestyle risk behaviors among adolescents depends on access to age-appropriate health promotion information. Chatbots-computer programs designed to simulate conversations with human users-have the potential to deliver health information to adolescents to improve their lifestyle behaviors and support behavior change, but research on the feasibility and acceptability of chatbots in the adolescent population is unknown. OBJECTIVE: This systematic scoping review aims to evaluate the feasibility and acceptability of chatbots in nutrition and physical activity interventions among adolescents. A secondary aim is to consult adolescents to identify features of chatbots that are acceptable and feasible. METHODS: We searched 6 electronic databases from March to April 2022 (MEDLINE, Embase, Joanna Briggs Institute, the Cumulative Index to Nursing and Allied Health, the Association for Computing Machinery library, and the IT database Institute of Electrical and Electronics Engineers). Peer-reviewed studies were included that were conducted in the adolescent population (10-19 years old) without any chronic disease, except obesity or type 2 diabetes, and assessed chatbots used nutrition or physical activity interventions or both that encouraged individuals to meet dietary or physical activity guidelines and support positive behavior change. Studies were screened by 2 independent reviewers, with any queries resolved by a third reviewer. Data were extracted into tables and collated in a narrative summary. Gray literature searches were also undertaken. Results of the scoping review were presented to a diverse youth advisory group (N=16, 13-18 years old) to gain insights into this topic beyond what is published in the literature. RESULTS: The search identified 5558 papers, with 5 (0.1%) studies describing 5 chatbots meeting the inclusion criteria. The 5 chatbots were supported by mobile apps using a combination of the following features: personalized feedback, conversational agents, gamification, and monitoring of behavior change. Of the 5 studies, 2 (40.0%) studies focused on nutrition, 2 (40.0%) studies focused on physical activity, and 1 (20.0%) focused on both nutrition and physical activity. Feasibility and acceptability varied across the 5 studies, with usage rates above 50% in 3 (60.0%) studies. In addition, 3 (60.0%) studies reported health-related outcomes, with only 1 (20.0%) study showing promising effects of the intervention. Adolescents presented novel concerns around the use of chatbots in nutrition and physical activity interventions, including ethical concerns and the use of false or misleading information. CONCLUSIONS: Limited research is available on chatbots in adolescent nutrition and physical activity interventions, finding insufficient evidence on the acceptability and feasibility of chatbots in the adolescent population. Similarly, adolescent consultation identified issues in the design features that have not been mentioned in the published literature. Therefore, chatbot codesign with adolescents may help ensure that such technology is feasible and acceptable to an adolescent population.

An analysis of current obesity strategies for adolescents in NSW against best practice recommendations: Implications for researchers, policymakers and practitioners.

ISSUE ADDRESSED: Obesity is a significant health challenge facing adolescents. There is a critical need for government action to support all adolescents to improve risk factors for obesity. This study critically appraised initiatives, guidelines and policies (termed "strategies") from local health districts (LHDs), speciality health networks and Primary Health Networks (PHNs) across New South Wales (NSW), relevant to the prevention and management of obesity amongst adolescents and compare these to best practice recommendations. METHODS: We critically appraised strategies against best practice recommendations that included support, access, responsiveness to needs, supportive environment, monitoring and evaluation and health equity. Strategies were collected by systematically searching websites of 15 LHDs, one speciality health network and 10 PHNs. RESULTS: There was evidence of strategies regarding adolescent obesity prevention and management across all best practice recommendations. There was limited evidence of adolescent consumer participation, digital strategies for health services and online health information. There were minimal targeted public or school-based education campaigns and interventions on physical activity or nutrition. Place-based approaches such as sports and recreation facilities were not included in policies regarding the sale of healthy food and drinks. Evaluation evidence across all strategies was minimal. CONCLUSIONS: Numerous strategies are being implemented across NSW to address adolescent obesity. Despite this, the alignment of strategies with best practice recommendations is poor and evidence of progress in tackling adolescent obesity remains unclear. SO WHAT?: Opportunities to generate and translate best practice evidence within government strategies for obesity must be prioritised with embedded measurement and evaluation plans.

Supporting women's health outcomes after breast cancer treatment comparing a text message intervention to usual care: the EMPOWER-SMS randomised clinical trial.

PURPOSE: The aim of this study is to evaluate the efficacy, feasibility and acceptability of a co-designed lifestyle-focused text message intervention (EMPOWER-SMS) for breast cancer survivors' self-efficacy, quality of life (QOL), mental (anxiety, depression, stress) and physical (endocrine therapy medication adherence, physical activity, BMI) health. METHODS: Single-blind randomised controlled trial (1:1) comparing EMPOWER-SMS to usual care at 6-months (intention-to-treat). SETTING: public Breast Cancer Institute (Sydney, Australia). ELIGIBILITY CRITERIA: adult (> 18 years) females, < 18-months post-active breast cancer treatment (stage I-III), owned a mobile phone, written informed consent. PRIMARY OUTCOME: Self-Efficacy for Managing Chronic Disease Scale at 6 months. Process data: message delivery analytics, cost, and post-intervention survey. RESULTS: Participants (N = 160; mean age ± SD 55.1 ± 11.1 years) were recruited 29th-March-2019 to 7th-May-2020 and randomised (n = 80 EMPOWER-SMS: n = 80 control). Baseline mean self-efficacy was high (I: 7.1 [95%CI 6.6, 7.5], C: 7.4 [7, 7.8]). Six-month follow-up: no significant differences between groups for self-efficacy (I: 7.6 [7.3, 7.9], C: 7.6 [7.3, 7.9], adjusted mean difference 0 (95%CI 0.4, 0.4), QOL, mental health, physical activity, or BMI. Significantly less EMPOWER-SMS participants missed ≥ 1 endocrine therapy medication doses compared to control (I: 3/42[7.1%], C: 8/47[17.0%], Adjusted RR 0.13 [95%CI 0.02, 0.91]). Text messages were delivered successfully (7925/8061, 98.3%), costing $13.62USD/participant. Participants strongly/agreed EMPOWER-SMS was easy-to-understand (64/64; 100%), useful (58/64; 90.6%), motivating for lifestyle change (43/64; 67.2%) and medication adherence (22/46; 47.8%). CONCLUSION: EMPOWER-SMS was feasible, inexpensive, acceptable for delivering health information to breast cancer survivors between medical appointments, with minor improvements in medication adherence. IMPLICATIONS FOR CANCER SURVIVORS: Text messages offer a feasible strategy for continuity-of-care between medical appointments.

Lung Support Service: Implementation of a Nationwide Text Message Support Program for People with Chronic Respiratory Disease during the COVID-19 Pandemic.

BACKGROUND: COVID-19 pandemic lockdowns led to the closure of most in-person pulmonary rehabilitation programs in Australia. Text message programs are effective for delivering health support to aid the self-management of people with chronic diseases. This study aimed to evaluate the implementation of a six-month pre-post text message support program (Texting for Wellness: Lung Support Service), and the enablers and barriers to its adoption and implementation. METHODS: This mixed-methods pre-post study used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate the Texting for Wellness: Lung Support Service, which is an automated six-month text message support program that included evidence-based lifestyle, disease-self management and COVID-19-related information. Reach was measured by the proportion of participant enrolments and demographic characteristics. Adoption enablers and barriers were measured using text message response data and a user feedback survey (five-point Likert scale questions and free-text responses). Implementation was evaluated to determine fidelity including text message delivery data, opt-outs, and intervention costs to promote and deliver the program. RESULTS: In total, 707/1940 (36.4%) participants enrolled and provided e-consent, with a mean age (±standard deviation) of 67.9 (±9.2) years old (range: 23-87 years). Of participants who provided feedback, (326/707) most 'agreed' or 'strongly agreed' that the text messages were easy to understand (98.5%), helpful them to feel supported (92.3%) and helped them to manage their health (88.0%). Factors influencing engagement included a feeling of support and reducing loneliness, and its usefulness for health self-management. Messages were delivered as planned (93.7% successfully delivered) with minimal participant dropouts (92.2% retention rate) and low cost ($AUD24.48/participant for six months). A total of 2263 text message replies were received from 496 unique participants. There were no reported adverse events. CONCLUSION: Texting for Wellness: Lung Support Service was implemented quickly, had a broad reach, with high retention and acceptability among participants. The program was low cost and required minimal staff oversight, which may facilitate future implementation. Further research is needed to evaluate the efficacy of text messaging for the improvement of lung health outcomes and strategies for long-term pulmonary rehabilitation program maintenance.

Unhealthy Food at Your Fingertips: Cross-Sectional Analysis of the Nutritional Quality of Restaurants and Takeaway Outlets on an Online Food Delivery Platform in New Zealand.

Online food delivery (OFD) platforms have become increasingly popular due to advanced technology, which is changing the way consumers purchase food prepared outside of the home. There is limited research investigating the healthiness of the digital food environment and its influence on consumer choice and dietary behaviours. This study is the first to examine the nutritional quality and marketing attributes of menu items from popular independent and franchise restaurants and takeaway outlets on New Zealand's market leading OFD platform (UberEATS®). A total of 374 popular independent and franchise restaurants and takeaway outlets were identified to form a database of complete menus and marketing attributes. All 25,877 menu items were classified into 38 food and beverage categories based on the Australian Dietary Guidelines. Of complete menus, 73.3% (18,955/25,877) were discretionary. Thirty-six percent (9419/25,877) were discretionary cereal-based mixed meals, the largest of the 38 categories. Discretionary menu items were more likely to be categorized as most popular (OR: 2.0, 95% CI 1.7−2.2), accompanied by a photo (OR: 1.7, 95% CI 1.6−1.8), and offered as a value bundle (OR: 4.6, 95% CI 3.2−6.8). Two of the three discretionary mixed meal categories were significantly less expensive than their healthier counterparts (p < 0.001). The overwhelming availability and promotion of discretionary choices offered by restaurants and takeaway outlets on OFD platforms have implications for public health policy. Further research to explore direct associations between nutritional quality and consumers' dietary choices is required.

A healthy lifestyle text message intervention for adolescents: protocol for the Health4Me randomized controlled trial.

BACKGROUND: Adolescence presents a window of opportunity to establish good nutrition and physical activity behaviours to carry throughout the life course. Adolescents are at risk of developing cardiovascular and other chronic diseases due to poor the complex interplay of physical and mental health lifestyle risk factors. Text messaging is adolescents main form of everyday communication and text message programs offer a potential solution for support and improvement of lifestyle health behaviours. The primary aim of this study is to determine effectiveness of the Health4Me text message program to improve adolescent's physical activity or nutrition behaviours among adolescents over 6-months, compared to usual care. METHODS: Health4Me is a virtual, two-arm, single-blind randomised controlled trial, delivering a 6-month healthy lifestyle text message program with optional health counselling. Recruitment will be through digital advertising and primary care services. In total, 330 adolescents will be randomised 1:1 to intervention or control (usual care) groups. The intervention group will receive 4-5 text messages per week for 6-months. All text messages have been co-designed with adolescents. Messages promote a healthy lifestyle by providing practical information, health tips, motivation and support for behaviour change for physical activity, nutrition, mental health, body image, popular digital media and climate and planetary health. Virtual assessments will occur at baseline and 6-months assessing physical health (physical activity, nutrition, body mass index, sleep), mental health (quality of life, self-efficacy, psychological distress, anxiety, depression, eating disorder risk) and lifestyle outcomes (food insecurity and eHealth literacy). DISCUSSION: This study will determine the effectiveness of a 6-month healthy lifestyle text message intervention to improve physical activity and nutrition outcomes in adolescents. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622000949785 , Date registered: 05/07/2022.

Electronic Health Interventions for Patients With Breast Cancer: Systematic Review and Meta-Analyses.

PURPOSE: Ongoing supportive care using electronic health (eHealth) interventions has the potential to provide remote support and improve health outcomes for patients with breast cancer. This study aimed to evaluate the effectiveness of eHealth interventions on patient-reported outcomes (quality of life [QOL], self-efficacy, and mental or physical health) for patients during and after breast cancer treatment and patient-reported experience measures (acceptability and engagement). METHODS: Systematic review with meta-analyses (random-effects model) of randomized controlled trials was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Nine databases were searched using a prespecified search strategy. Patient-directed eHealth interventions for adult patients during or after active breast cancer treatment measuring QOL, self-efficacy, and mental (depressive, anxiety, and distress symptoms) or physical (physical activity, nutrition, and fatigue) health outcomes were included. Data from eligible full-text articles were independently extracted by six observers. RESULTS: Thirty-two unique studies (4,790 patients) were included. All were health self-management interventions, and most were multicomponent (videos, forums, and electronic reminder systems) websites. Meta-analyses revealed a significant effect of eHealth interventions on QOL (standardized mean difference [SMD], 0.20 [95% CI, 0.03 to 0.36]), self-efficacy (SMD, 0.45 [95% CI, 0.24 to 0.65]), distress (SMD, -0.41 [95% CI,-0.63 to -0.20]), and fatigue (SMD, -0.37 [95% CI, -0.61 to -0.13]). Twenty-five studies (78.1%) measured patient-reported experience measures. Acceptability (n = 9) was high, with high ratings for satisfaction (range, 71%-100%), usefulness (range, 71%-95%), and ease-of-use (range, 73%-92%). Engagement (n = 25) decreased over time, but disease-focused information and interactive support were most engaging. CONCLUSION: eHealth interventions may provide an acceptable and effective strategy for improving QOL, distress, self-efficacy, and fatigue among patients with breast cancer.

Underinvestment in nutrition research for at-risk populations: An analysis of research funding awarded in Australia from 2014 to 2021.

AIM: To determine the proportion of research projects funded by the National Health and Medical Research Council and Australian Research Council research funding from 2014 to 2021 that aimed to understand or improve dietary behaviours for at-risk populations in Australia and estimate the proportion of total funding allocated during this period. METHODS: Retrospective analysis of the publicly available National Health and Medical Research Council and Australian Research Council funding grants over the 8 years from 2014 to 2021 (n = 18 098). At-risk dietary populations included people living in rural and remote Australia, Aboriginal and Torres Strait Islander people, or people living in socioeconomically disadvantaged areas. Descriptive analysis was undertaken. RESULTS: In total, 144 out of 18 098 (0.8%) individual grants totalling $96.8 million were identified relating to nutrition research from 2014 to 2021. Out of the 144, only 21 ($19.6 million; 0.1%) of all National Health and Medical Research Council grants were identified for nutritionally at-risk populations, with the majority focused on Aboriginal and Torres Strait Islander people (15/21). The National Health and Medical Research Council and Australian Research Council grants that aimed to improve human dietary behaviours increased by 0.66% and 0.58%, respectively, from 2014 to 2021. However, the National Health and Medical Research Council grants aiming to improve nutritional behaviours in at-risk populations decreased by 0.04% over the 8 years. CONCLUSIONS: Despite slight increases in the proportions of funding to improve dietary behaviours over the past decade, nutrition research specifically targeting at-risk groups is scarce and appears to have decreased over time. Insufficient investment in research for these groups presents a risk for widening health disparities now and into the future. As such, they must be further supported and considered in the design of future funding schemes.

Navigating the Online World of Lifestyle Health Information: Qualitative Study With Adolescents.

BACKGROUND: Adolescence is a critical life stage characterized by an interplay of biological, social, and environmental factors. Such factors influence lifestyle health-related trajectories, including dietary behaviors, physical activity levels, body weight, and sleep. Generation Z (born 1995-2015) is the most internet-dependent and technologically savvy generation in history with increasing rates of smartphone ownership across high- and low-income countries. Gaps exist in understanding what online platforms adolescents are using and barriers and facilitators of these platforms to seek lifestyle health information. OBJECTIVE: We evaluated adolescents' perceptions on the use of contemporary digital platforms (websites, social media platforms, smartphone apps) to seek lifestyle heath information or advice. METHODS: Virtual focus groups were held via Zoom teleconference between July 2021 and August 2021. Eligible participants were 13 years to 18 years old, were living in Australia, and had searched for online lifestyle health information in the previous 3 months. For this study, lifestyle health information referred to key behaviors and risk factors for chronic disease, namely, diet, physical activity, weight management, and sleep. Participants were recruited through an existing database of research participants and networks of the research team. Focus groups were analyzed using the framework approach, in which data are systematically searched to recognize patterns in the data and manage, analyze, and identify themes. Focus group audio files were transcribed verbatim and independently coded by 2 researchers (RR, SSJ). Through an iterative, reflexive process, a final coding matrix was agreed on by all researchers and used to thematically analyze the data. RESULTS: We held 5 focus groups (n=32; mean age: 16.3 [SD 1.4] years; 18/32, 56% female; 13/32, 41% spoke language other than English at home). Thematic analysis revealed participants searched for information both actively (eg, on Google or YouTube) and passively (eg, scrolling social media and using existing apps preloaded to their smartphone such as Apple Health, Samsung Health, or Google Fit apps). Participants identified that the most helpful information was well-presented in terms of aesthetic appeal and layout and came from a credible and reliable source (eg, any sponsorships disclosed), and they expressed the need for the information to be relatable. Mixed views were reported for the application of lifestyle health information found online. Some participants reported behavior change, while others noted that certain advice was hard to maintain and incorporate into their lifestyle. CONCLUSIONS: This study highlights the abundance and complexity of lifestyle health information online for adolescents. Adolescents in the digital age seek access to information that is appealing, credible, relevant, and actionable for lifestyle health behaviors. To appeal to needs of adolescents, future interventions for adolescents relating to lifestyle health must consider co-design methodological approaches. Furthermore, the regulation of lifestyle health information available online warrants further investigation.

Supporting breast cancer survivors via text messages: reach, acceptability, and utility of EMPOWER-SMS.

PURPOSE: This study aims to evaluate the reach, usefulness, acceptability, and factors influencing engagement with a lifestyle-focused text message intervention to support women's mental and physical health after breast cancer treatment. METHODS: This study uses a mixed-methods process evaluation nested in the EMPOWER-SMS randomised controlled trial (n = 160; intervention n = 80, wait-list control n = 80). Data sources included screening logs, text message delivery software analytics, intervention feedback survey, and focus groups (n = 16), which were summarised thematically based on the framework approach. RESULTS: A total of 387 women met the inclusion criteria (meanage ± SD = 59.3 ± 11.6 years). Participants who declined (n = 227) were significantly older than those who enrolled (n = 160; 62.2 ± 11.1 vs 55.1 ± 11.1 years, respectively, p < 0.001). Most intervention participants (64/80; 80%) completed the end-of-study survey, reporting the messages were easy to understand (64/64; 100%), useful (58/64; 91%), and motivating (43/64; 67%). The focus groups (n = 16) revealed five factors influencing engagement: (i) feelings of support/continued care, (ii) convenience/flexibility of message delivery, (iii) weblinks, (iv) information from a credible source, and (v) options to save or share messages. CONCLUSION: A lifestyle-focused text message program was acceptable and useful for women after breast cancer treatment. However, text messaging may be a barrier for women aged over 68 years. Suggestions for program improvements included delivering the program to patients with other cancers, during all stages of treatment, and including more weblinks in text messages. Implications for Cancer Survivors Text message programs offer a low-cost way to deliver post-treatment health support to breast cancer survivors in a non-invasive way. Text messages can improve patient-health professional communication and were found to be acceptable and useful.