Was it a HIIT? A process evaluation of a school-based high-intensity interval training intervention.

BACKGROUND: Despite a growing body of research investigating high-intensity interval training (HIIT) in schools, there are limited process evaluations investigating their implementation. This is concerning because process evaluations are important for appropriately interpreting outcome findings and augmenting intervention design. This manuscript presents a process evaluation of Making a HIIT, a school-based HIIT intervention. METHODS: The Making a HIIT intervention spanned 8 weeks and was completed at three schools in Greater Brisbane, Australia. Ten classes (intervention group) completed 10-min teacher-led HIIT workouts at the beginning of health and physical education (HPE) lessons, and five classes (control group) continued with regular HPE lessons. The mixed methods evaluation was guided by the Framework for Effective Implementation by Durlak and DuPre. RESULTS: Program reach: Ten schools were contacted to successfully recruit three schools, from which 79% of eligible students (n = 308, x ¯ age: 13.0 ± 0.6 years, 148 girls) provided consent. Dosage: The average number of HIIT workouts provided was 10 ± 3 and the average number attended by students was 6 ± 2. Fidelity: During HIIT workouts, the percentage of time students spent at ≥ 80% of maximum heart rate (HRmax) was 55% (interquartile range (IQR): 29%-76%). Monitoring of the control group: During lessons, the intervention and control groups spent 32% (IQR: 12%-54%) and 28% (IQR: 13%-46%) of their HPE lesson at ≥ 80% of HRmax, respectively. Responsiveness: On average, students rated their enjoyment of HIIT workouts as 3.3 ± 1.1 (neutral) on a 5-point scale. Quality: Teachers found the HIIT workouts simple to implement but provided insights into the time implications of integrating them into their lessons; elements that helped facilitate their implementation; and their use within the classroom. Differentiation: Making a HIIT involved students and teachers in the co-design of HIIT workouts. Adaption: Workouts were modified due to location and weather, the complexity of exercises, and time constraints. CONCLUSION: The comprehensive evaluation of Making a HIIT provides important insights into the implementation of school-based HIIT, including encouragings findings for student enjoyment and fidelity and recommendations for improving dosage that should be considered when developing future interventions. TRIAL REGISTRATION: ACTRN, ACTRN12622000534785 , Registered 5 April 2022 - Retrospectively registered.

Exploring the long-term sustainability of school-based nutrition and food programs: What works, where and why?

ISSUE ADDRESSED: Most food and nutrition programs cease within 2 years. Understanding the determinants of program sustainability is crucial to maximise output from funding, whilst allowing sufficient time for program benefits to be achieved. This study applied the Consolidated Framework for Implementation Research (CFIR) to map the barriers and enablers of successful long-term implementation of school-based nutrition and food programs. METHODS: Qualitative methods with purposive and snowball sampling were used to recruit experts who were identified as being influential in implementing and sustaining long-term (>2 years) school-based food and nutrition programs. Semi-structured interviews with global experts were conducted, transcribed verbatim and coded deductively (by applying the CFIR constructs) and inductively when required. Thematic analysis informed the development of themes. RESULTS: Interviews were conducted with 11 experts including researchers, government employees, and a consultant of an international agency, from seven countries. Forty-eight deductive codes and eight inductive codes identified six main themes: (1) funding and integrity of its source; (2) political landscape; (3) nutrition policies and their monitoring; (4) involvement of community actors; (5) adaptability of the program and (6) effective program evaluation. Themes related mainly to the 'outer setting' domain of the CFIR. CONCLUSIONS: The CFIR highlighted pertinent factors that influence the successful long-term implementation of school-based food and nutrition programs. SO WHAT?: The findings suggest that to sustain program implementation beyond its initial funding, relationships across government departments, local organisations and communities, need to be nurtured and prioritised from the outset.

Healthier Together: Implementation and evaluation of a co-designed, culturally tailored childhood obesity community prevention program for Maori and Pacific Islander children and families.

ISSUE ADDRESSED: Co-designed and culturally tailored preventive initiatives delivered in childhood have high potential to close the cross-cultural gap in health outcomes of priority populations. Maori and Pacific Islander people living in Australia exhibit a higher prevalence of overweight and obesity and higher rates of multimorbidity, including heart disease, cancer and diabetes. METHODS: This mixed-methods, pilot implementation and evaluation study, aimed to evaluate the implementation of a community-based, co-designed and culturally tailored childhood obesity prevention program, using quantitative (pre-post anthropometric measurement, pre-post health behaviour questionnaire) and qualitative (semi-structured interview) methods. Sessions relating to healthy eating, physical activity and positive parenting practices were delivered to families residing in Brisbane (Australia) over 8-weeks. RESULTS: Data were collected from a total of 66 children (mean age 11, SD 4) and 38 parents (mean age 40, SD 8) of Maori and Pacific Islander background, from July 2018 to November 2019. Anthropometric changes included a reduction in Body Mass Index (BMI) z-score among 59% of children (median change -0.02, n = 38, p = 0.17) and BMI among 47% of adults (median change +0.06 kg/m2 , n = 18, p = 0.64). Significant improvements (p < 0.05) in self-reported health behaviours from pre- to post-program included increased vegetable consumption among children, decreased discretionary food intake of children, decreased discretionary drink consumption among both children and adults, increased minutes of daily physical activity among adults and increased parental confidence in the healthy diets of their children. Qualitative data revealed participants valued the inclusion of all family members, learning of practical skills and cultural tailoring delivered by the Multicultural Health Coaches. CONCLUSIONS: This study provides preliminary evidence that the Healthier Together program improved self-reported health behaviours and physical activity levels among Maori and Pacific Islander children and their families in the short-term; however, due to the small sample size, these results must be interpreted carefully. The program empowered change via cultural tailoring and accessibility; however, long-term implementation and evaluation with a larger cohort is needed to validate the observed health behaviour improvements and their sustainability. SO WHAT?: The co-design framework that informed program development and key learnings of implementation will provide guidance to health practitioners, health workers, public health professionals and policy makers to develop inclusive and pragmatic co-design solutions for priority cultural populations in Australia. Health outcomes will improve as a result, promoting health equity for future generations.

Dietary Strategies for Obesity.

Overweight and obesity remains an important health focus internationally, due to the strong link to many noncommunicable diseases, such as cardiovascular disease, non-alcoholic fatty liver disease, diabetes mellitus and mental health conditions [...].

Making a HIIT: co-design of high-intensity interval training workouts with students & teachers within the curriculum.

BACKGROUND: High-intensity interval training (HIIT) interventions are becoming more common in schools. However, limited input has been sought from end-users, which can help design interventions that are more engaging and context appropriate, therefore increasing their potential for successful implementation. One method of engaging end-users is co-design, which involves an active collaboration to design solutions to pre-specified problems. This paper aimed to: (1) describe the methodology and results of the co-design process in Making a HIIT to develop HIIT workouts for a school-based intervention; and (2) evaluate the feasibility and impact of co-designing HIIT workouts with students and teachers within the health and physical education (HPE) curriculum. METHODS: The development of the HIIT workouts occurred during obligatory HPE lessons with year seven and eight students. The co-design process included: (1) identifying barriers and facilitators to exercise to create evaluation criteria for creating the HIIT workouts; (2) exploring HIIT; (3) defining HIIT parameters (intensity and interval length); (4) creating HIIT workouts using the parameters and evaluation criteria; (5) trialling and modifying the HIIT workouts based on class feedback and intensity data. To evaluate the feasibility and impact of the co-design process, a thematic analysis was completed using teacher interviews, student discussions, and student surveys. RESULTS: Five classes comprised of 121 students (12-14 years; 49% female) and five teachers were involved in the co-design process across three schools in Queensland, Australia. A total of 33 HIIT workouts were created aimed at satisfying the HIIT parameters and variations of the following evaluation criteria: (1) fun; (2) social; (3) achievable skill level; (4) feeling accomplished; and (5) beneficial for health. From the thematic analysis, three themes (acceptability; implementation; integration) and 12 codes contributed to the overarching understanding of the feasibility of the lessons within the curriculum and a further three themes (perceived changes to lessons; educative outcomes; personal and social capabilities) and three codes contributed towards understanding their impact. CONCLUSION: Overall, co-designing HIIT workouts was feasible within the HPE curriculum and may have contributed to positive educative outcomes. Using this methodology could improve the implementation of HIIT interventions within HPE while supporting educative benefits.

Dietary Patterns of Competitive Swimmers with Moderate-to-Severe Cerebral Palsy: A 3-Year Longitudinal Evaluation.

AIM: To evaluate the longitudinal dietary patterns of three adolescents with moderate-to-severe cerebral palsy (CP) participating in a performance-focused swimming training intervention. METHOD: Participants were three previously inactive adolescents with CP (15-16 years, GMFCS IV) who had recently (<6 months) enrolled in a swimming training program. Diet quality from diet histories was calculated at 10-time points over 3.25 years using the Dietary Guidelines Index for Children and Adolescents (DGI-CA) and the Healthy Eating Index for Australian Adults (HEIFA-2013). A food group analysis was compared to the Australian Guide to Healthy Eating recommendations. Trends were considered in the context of dietary advice given and the training load. RESULTS: Longitudinal diet quality scores were consistent and ranged from 40 to 76 (DGI-CA) and 33 to 79 (HEIFA-2013). Food group intake remained stable; participants rarely met the recommendations for fruit, vegetables, dairy, grain, and meat but frequently achieved discretionary serves. CONCLUSIONS: Participants with moderate-to-severe CP who were enrolled in a performance-focused swimming training intervention and were monitored frequently maintained diet quality throughout a period where it conventionally declined. Scores were higher than the general population and were maintained irrespective of the training load. Participants frequently met food group recommendations for discretionary foods and were comparable to the general population for other food groups.

"We'd be really motivated to do something about it": A qualitative study of parent and clinician attitudes towards predicting childhood obesity in practice.

ISSUE ADDRESSED: In Australia, one in four (24.9%) children live with overweight or obesity (OW/OB). Identifying infants at risk of developing childhood OW/OB is a potential preventive pathway, but its acceptability is yet to be investigated in Australia. This study aimed to (1) investigate the acceptability of predicting childhood OW/OB with parents of infants (aged 0-2 years) and clinicians and (2) explore key language to address stigma and maximise the acceptability of predicting childhood OW/OB in practice. METHODS: This was a cross-sectional and qualitative design, comprising individual semi-structured interviews. Participants were multidisciplinary paediatric clinicians (n = 18) and parents (n = 13) recruited across public hospitals and health services in Queensland, Australia. Data were analysed under the Framework Method using an inductive, thematic approach. RESULTS: Five main themes were identified: (1) Optimism for prevention and childhood obesity prediction, (2) parent dedication to child's health, (3) adverse parent response to risk for childhood obesity, (4) language and phrasing for discussing weight and risk and (5) clinical delivery. Most participants were supportive of using a childhood OW/OB prediction tool in practice. Parents expressed dedication to their child's health that superseded potential feelings of judgement or blame. When discussing weight in a clinical setting, the use of sensitive (ie, "overweight", "above average", "growth" versus "obesity") and positive, health-focused language was mostly supported. CONCLUSIONS: Multidisciplinary paediatric clinicians and parents generally accept the concept of predicting childhood OW/OB in practice in Queensland, Australia. SO WHAT?: Clinicians, public health and health promotion professionals and policymakers can act now to implement sensitive communication strategies concerning weight and obesity risk.

What Do Health Professionals and Parents Want as Part of an Online Childhood Obesity Prevention Program?

Background: There are limited evidence-based programs for children living in Queensland, Australia, who are at risk of overweight or obesity. Despite the known importance of prevention initiatives, an online, locally relevant program supporting sustainable health behaviors does not exist. This study aimed to understand the perspectives of parents/guardians and health professionals regarding important aspects of an online childhood obesity prevention program. Methods: This pragmatic, mixed-methods study was conducted from March to December 2020. Recruitment included participants from two groups involved with children aged 2-17 years, health professionals, and parents/guardians. Phase 1 involved dissemination of an online survey. Questions addressed program structure, content delivery (including nutrition, physical activity, and parenting practices), program evaluation, and information dissemination. Descriptive statistics were used to describe survey data to inform the delivery of Phase 2, where two focus groups further explored the topics. Thematic analysis was used to investigate the qualitative data. Results: Twenty-eight health professionals and 11 parents/guardians completed the survey, and 14 health professionals and 6 parents/guardians participated in the focus groups. Participants believed that the most beneficial approach would target younger children with family-based interventions, via a nontraditional structure. There was a strong preference for interactive content, gamification, and practical resources to translate knowledge into practice. Parents emphasized that there should be no assumption of basic knowledge, and that decision fatigue is a barrier to engagement. Conclusion: Participants provided clear direction regarding key aspects for future development of an online prevention program, highlighting the importance of codesign to tailor the program to identified needs.

Making a HIIT: Methods for quantifying intensity in high-intensity interval training in schools and validity of session rating of perceived exertion.

Using the data from Making a HIIT, this paper aimed to: 1) investigate the different heart rate (HR) quantification methods reported in school-based high-intensity interval training (HIIT) studies; and 2) assess the criterion validity of session rating of perceived exertion (RPE). During an 8-week HIIT intervention, 213 students (13.1 (0.6) years; 46% female) completed 10-minute HIIT workouts during physical education lessons. In total, 1057 HR and RPE measurements were collected across 68 HIIT workouts. For aim 1, the average and peak HR across all participants and workouts were 79% (8%) and 92% (6%) of HRmax, respectively. The average RPE was 6 (2) points on a 10-point scale. An average of 51% of students in a class had an average HR ≥ 80% for each workout. The between-person variation for peak and average HR were 19% and 30% , respectively. Both average and peak HR decreased by 0.5% each week (p < 0.001). To assess aim 2, a within-participant correlation was calculated for the internal training load produced using HR and RPE data. The correlation was 0.39 (p < 0.001), which suggests utility of using RPE when HR is not a viable option.

Dietary intake and educational outcomes among Australian university students: cross-sectional and longitudinal associations.

OBJECTIVE: This study aimed to examine cross-sectional and longitudinal associations between dietary intake and educational outcomes (EO) in Australian first-year university students. DESIGN: This cross-sectional and longitudinal study measured outcomes of interest at three points over 1 year. Measures included self-reported dietary patterns and dietary intake via a three-day estimated food record. Objective EO (corresponding semester grade point average (GPA), overall GPA and graduation status) variables were extracted from academic records. Cross-sectional and longitudinal associations were examined using regression models and generalised estimating equations, respectively. SETTING: A large university in Queensland, Australia. PARTICIPANTS: Participants (n 80) were first-year students who had completed high school in the previous year. RESULTS: Some significant associations were found with semester GPA, including: (a) moderate positive associations between serves of vegetables and semester GPA at time point 2 and over time; and (b) a weak negative association between Na intake and semester GPA at time point 2. Although insignificant, meaningful negative associations were found between alcohol consumption and semester GPA at time point 1 and over time. Some significant associations were also found with graduation status, including: (a) a positive association between meeting Australian carbohydrate recommendations and graduation status; and (b) a negative association between Fe intake and graduation status, both at time point 1. CONCLUSIONS: Both cross-sectional and longitudinal findings highlight positive associations between vegetable intake and EO and negative associations between alcohol consumption and EO. Further relevant work is needed with larger, more variable samples in demographic, dietary and EO characteristics.

Making a HIIT: study protocol for assessing the feasibility and effects of co-designing high-intensity interval training workouts with students and teachers.

BACKGROUND: High-intensity interval training (HIIT) is an effective strategy for improving a variety of health outcomes within the school setting. However, there is limited research on the implementation of school-based HIIT interventions and the integration of HIIT within the Health and Physical Education (HPE) curriculum. The aims of the Making a HIIT study are to: 1) describe the methodology and evaluate the feasibility of co-designing HIIT workouts with students and teachers in HPE; 2) determine the effect of co-designed HIIT workouts on cardiorespiratory and muscular fitness, and executive function; 3) understand the effect of co-design on students' motivation, enjoyment, and self-efficacy towards the workouts; and 4) evaluate the implementation of the intervention. METHODS: Three schools will participate. Within each school, three different groups will be formed from Year 7 and 8 classes: 1) Co-Designers; 2) HIIT Only; and 3) Control. The study will include two phases. In phase one, Group 1 will co-design HIIT workouts as part of the HPE curriculum using an iterative process with the researcher, teacher, and students as collaborators. This process will be evaluated using student discussions, student surveys, and teacher interviews. In phase two, Groups 1 and 2 will use the co-designed 10-minute HIIT workouts in HPE for 8-weeks. Group 3 (control) will continue their regular HPE lessons. All students will participate in cardiorespiratory fitness, muscular fitness, and executive function assessments before and after the HIIT program or control period. Students will complete questionnaires on their motivation, enjoyment, and self-efficacy of the workouts. Differences between groups will be assessed using linear regressions to account for covariates. Heart rate and rating of perceived exertion will be collected during each HIIT session. The implementation will be evaluated using the Framework for Effective Implementation. Ethical approval was granted by the University of Queensland Human Research Ethics Committee and other relevant bodies. DISCUSSION: This study will be the first to co-design HIIT workouts with teachers and students within the HPE curriculum. As this study relies on co-design, each HIIT workout will differ, which will add variability between HIIT workouts but increase the ecological validity of the study. TRIAL REGISTRATION: ACTRN, ACTRN12622000534785, Registered 5 April 2022 - Retrospectively registered, https://www.anzctr.org.au/ACTRN12622000534785.aspx.

School-based high-intensity interval training programs in children and adolescents: A systematic review and meta-analysis.

PURPOSE: 1) To investigate the effectiveness of school-based high-intensity interval training (HIIT) interventions in promoting health outcomes of children and adolescents compared with either a control group or other exercise modality; and 2) to explore the intervention characteristics and process outcomes of published school-based HIIT interventions. METHODS: We searched Medline, Embase, CINAHL, SPORTDiscus, and Web of Science from inception until 31 March 2021. Studies were eligible if 1) participants aged 5-17 years old; 2) a HIIT intervention within a school setting ≥ 2 weeks duration; 3) a control or comparative exercise group; 4) health-related, cognitive, physical activity, nutrition, or program evaluation outcomes; and 5) original research published in English. We conducted meta-analyses between HIIT and control groups for all outcomes with ≥ 4 studies and meta-regressions for all outcomes with ≥ 10 studies. We narratively synthesised results between HIIT and comparative exercise groups. RESULTS: Fifty-four papers met eligibility criteria, encompassing 42 unique studies (35 randomised controlled trials; 36 with a high risk of bias). Meta-analyses indicated significant improvements in waist circumference (mean difference (MD) = -2.5cm), body fat percentage (MD = -1.7%), body mass index (standardised mean difference (SMD) = -1.0), cardiorespiratory fitness (SMD = +1.0), resting heart rate (MD = -5bpm), homeostatic model assessment-insulin resistance (MD = -0.7), and low-density lipoprotein cholesterol (SMD = -0.9) for HIIT compared to the control group. Our narrative synthesis indicated mixed findings between HIIT and other comparative exercise groups. CONCLUSION: School-based HIIT is effective for improving several health outcomes. Future research should address the paucity of information on physical activity and nutrition outcomes and focus on the integration and long-term effectiveness of HIIT interventions within school settings. TRIAL REGISTRATION NUMBER: PROSPERO CRD42018117567.

Adherence to Dietary and Physical Activity Guidelines in Australian Undergraduate Biomedical Students and Associations with Body Composition and Metabolic Health: A Cross-Sectional Study.

There is a paucity of data on whether Australian university students are meeting specific nutrient guidelines, and the relationship between diet and physical activity patterns with body composition and metabolic health. In this study, biomedical students from The University of Queensland were recruited (150 males and 211 females, 19-25 years), and nutritional intake (ASA24-Australia) and physical activity levels (Active Australia Survey) quantified. Body composition (height, waist circumference, body mass, BMI, and percentage body fat; BOD POD) and metabolic health (oral glucose tolerance test) were also measured. Median daily energy intake was 6760 kJ in females and 10,338 kJ in males, with more than 30% of total energy coming from energy-dense, nutrient-poor foods. Only 1 in 10 students met fruit or vegetable recommendations, with less than one third meeting recommendations for fibre, calcium, and potassium. Intakes of calcium and iron were particularly low among female students, with only 16% and 6% of students meeting the recommended dietary intake (RDI), respectively. The majority of males and almost half of all females exceeded the suggested dietary target (SDT) for sodium. Sufficient physical activity (≥150 min over ≥5 sessions per week) was met by more than 80% of students. Body composition and blood glucose concentrations were largely normal but an early sign of insulin resistance (HOMA-IR > 2.0), measured in a subset of students, was present in 21% of males and 17% of females. Modest reductions in blood glucose levels and percentage body fat were associated with increasing vigorous activity. Low intakes of fibre, calcium, and potassium could be corrected by increasing fruit, vegetable, and dairy intake, and, among females, health promotion messages focusing on iron-rich foods should be prioritised. While these nutrient deficiencies did not translate into immediate metabolic heath concerns, dietary behaviours can track into adulthood and have lasting effects on overall health.

Response to 'Systematic reviews do not always capture context of real-world intervention programmes for childhood obesity' by Wild et al., 2021 in BMC Public Health.

In a correspondence to BMC Public Health, Wild et al. respond to our systematic review that synthesised results of interventions to prevent or treat childhood obesity in Maori and Pacific Islanders. Our review included the Whanau Pakari study as one of six included studies - a multidisciplinary intervention for Maori children and adolescents living with obesity led by their research team. Our review suggested that future research can incorporate stronger co-design principles when designing culturally-tailored interventions to maximise cultural specificity, enhance engagement, facilitate program ownership and contribute to improved health and weight-related outcomes. We commend Whanau Pakari and the team of Wild et al. on their sustained commitment to addressing obesity in priority populations and agree that systematic reviews struggle to capture real-world context of interventions for complex diseases such as obesity. In this article, we respond sequentially to the comments made by Wild et al. and (1) clarify the scope of our review article (2) reiterate our commendation of mixed-methods approaches that capture real-world context (3) explain a referencing error that caused a misinterpretation of our results (4) clarify our interpretation of some Whanau Pakari characteristics (5) welcome partnership to facilitate shared learning with Wild et al.

i-PATHWAY: Development and validation of a prediction model for childhood obesity in an Australian prospective birth cohort.

AIM: To develop and validate a model (i-PATHWAY) to predict childhood (age 8-9 years) overweight/obesity from infancy (age 12 months) using an Australian prospective birth cohort. METHODS: The Transparent Reporting of a multivariable Prediction model for individual Prognosis or Diagnosis (TRIPOD) checklist was followed. Participants were n = 1947 children (aged 8-9 years) from the Raine Study Gen2 - an Australian prospective birth cohort - who had complete anthropometric measurement data available at follow up. The primary outcome was childhood overweight or obesity (age 8-9 years), defined by age- and gender-specific cut-offs. Multiple imputation was performed to handle missing data. Predictors were selected using 2000 unique backward stepwise logistic regression models. Predictive performance was assessed via: calibration, discrimination and decision-threshold analysis. Internal validation of i-PATHWAY was conducted using bootstrapping (1000 repetitions) to adjust for optimism and improve reliability. A clinical model was developed to support relevance to practice. RESULTS: At age 8-9 years, 18.9% (n = 367) of children were classified with overweight or obesity. i-PATHWAY predictors included: weight change (0-1 year); maternal pre-pregnancy body mass index (BMI); paternal BMI; maternal smoking during pregnancy; premature birth; infant sleep patterns; and sex. After validation, predictive accuracy was acceptable: calibration slope = 0.956 (0.952-0.960), intercept = -0.052 (-0.063, -0.048), area under the curve = 0.737 (0.736-0.738), optimised sensitivity = 0.703(0.568-0.790), optimised specificity = 0.646 (0.571-0.986). The clinical model retained acceptable predictive accuracy without paternal BMI. CONCLUSIONS: i-PATHWAY is a simple, valid and clinically relevant prediction model for childhood overweight/obesity. After further validation, this model can influence state and national health policy for overweight/obesity screening in the early years.

Healthier Together: Co-design of a culturally tailored childhood obesity community prevention program for Maori & Pacific Islander children and families.

ISSUE ADDRESSED: Children of Maori & Pacific Islander descent living in Australia have a greater prevalence of overweight/obesity and an increased risk of adverse health outcomes. This study aimed to co-design Healthier Together, a community-based, childhood overweight/obesity prevention program tailored to Maori & Pacific Islander cultures. METHODS: Co-design involved a three-phase, iterative, participatory and experience-based process, guided by the Te Ara Tika: Guidelines for Maori Research Ethics to promote respect and equity. Following traditional oratory customs of Maori & Pacific Islander cultures, "talanoa" facilitated the collaborative program design with recruited Maori & Pacific Islander consumers, cultural advisors and health professionals. Co-design formulated program objectives, session plans, resources and evaluation tools. RESULTS: Co-design developed a 9-week community-based childhood overweight/obesity prevention program providing culturally tailored education across four themes: (a) nutrition (b) physical activity (c) positive parenting practices (d) culture and health. Strong community engagement developed a program highly tailored to the local Maori & Pacific Islander population. CONCLUSIONS: Co-design methodology promotes equity and inclusion of all stakeholders, acknowledges and caters to diversity and creates a medium for openness, respect and shared purpose. Community-led participatory approaches are pivotal to engaging and empowering communities to successfully improve health behaviours, particularly in tackling childhood overweight/obesity. SO WHAT?: Healthier Together is culturally significant to ensure relevance, effectiveness and sustainability. It is relevant and potentially adaptable to other priority populations across Australia and globally. Ultimately, the delivery of culturally tailored health care will contribute to a reduction in the health inequity experienced amongst priority populations.

Implementation of the 'Healthier Drinks at Healthcare Facilities' strategy at a major tertiary children's hospital in Brisbane, Australia.

OBJECTIVE: The World Health Organization recommends people reduce their free sugar consumption to <10% of daily energy intake. This study aimed to determine the viability of the 'Healthier Drinks at Healthcare Facilities' strategy to reduce the amount of free sugar available in beverages and influence consumer purchasing patterns. METHODS: Beverage environment modifications at a children's hospital limited the availability of less healthy options. Using a convergent parallel mixed-methods design, sales data from retail food outlets (n=7) and vending machines (n=14) were collected from January 2017 to May 2018. Employees (n=105) and visitors (n=102) completed surveys, and retail food outlet managers (n=3) completed semi-structured interviews. Data were analysed via descriptive statistics, independent t-tests and content analysis. RESULTS: The strategy decreased the availability of less healthy beverages and resulted in a significant increase in the proportion of 'green' (healthier) beverages sold (3%, p=0.002), and a decrease in the proportion of 'red' (less healthy) beverages sold (5%, p=0.011). Overall, sales did not change (p=0.243). The majority of participants supported the strategy. CONCLUSIONS: Overall, a shift in consumer purchasing patterns resulted. Further modification of the beverage environment is encouraged to increase impact. Implications for public health: This strategy was feasible and acceptable in a healthcare setting.

Interventions to prevent or treat childhood obesity in Maori & Pacific Islanders: a systematic review.

BACKGROUND: Maori and Pacific Islander people are a priority population originating from Australasia. Maori and Pacific Islander children exhibit greater risk of obesity and associated morbidities compared to children of other descent, secondary to unique cultural practices and socioeconomic disadvantage. Despite these known risk factors, there is limited synthesised evidence for preventing and treating childhood obesity in this unique population. The objective of this systematic review was to identify and evaluate global prevention or treatment interventions for overweight or obesity that targeted Maori and Pacific Islander children and adolescents (aged 2-17 years). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The databases PubMed, EMBASE, Scopus, Web of Science and CINAHL were searched from inception to August 2018. Study quality and risk of bias was assessed using a modified Downs and Black Quality Checklist for Health Care Intervention Studies. Studies were included if RCT/intervention/case control/ or prevention study designs. The study group was defined under the search term 'Oceanic Ancestry Group'. RESULTS: Of the initial 94 articles identified, six were included describing two prevention and three treatment interventions. Interventions were heterogenous in setting, design, length and outcomes. Four interventions were implemented in New Zealand. Most studies were of 'fair' quality. One study recruited an exclusive population of Maori and Pacific Islander participants. In the five studies that recruited mixed populations, one performed sub-group analysis on Maori and Pacific Islander participants. No study reported an improvement in anthropometric outcomes post-intervention in complete or sub-group analysis. Improvements in cardiometabolic or psychological secondary outcomes were inconsistent across all studies. CONCLUSIONS: There is a lack of evidence to recommend specific intervention characteristics to optimise obesity prevention or treatment outcomes for Maori and Pacific Islander children. Future research requires greater consideration of cultural values and beliefs, community engagement, exclusive targeting of Maori and Pacific Islander children and families, and sub-group analyses for mixed-population studies. Incorporating co-design principles during study design and implementation can maximise the cultural specificity of interventions and may contribute to improved health and weight-related outcomes for this at-risk, priority population. TRIAL REGISTRATION: PROSPERO CRD42019121790 (26 March 2019).

Adherence to the Mediterranean Diet and Chronic Disease in Australia: National Nutrition and Physical Activity Survey Analysis.

The Mediterranean diet (MD) is linked to decreased risk of chronic disease, such as cardiovascular disease, obesity, hypertension, diabetes mellitus and cognitive disease. Given the health promoting aspects of this diet, we conducted a secondary analysis of data from the National Nutrition and Physical Activity Survey (NNPAS), which is the largest health study in Australia and the first nutrition-specific national-based study. The primary aim of this analysis was to determine the proportion of Australian adults adhering to the MD and to examine the association between adherence to the MD and markers of noncommunicable diseases, such as cardiovascular disease, diabetes mellitus and chronic kidney disease. Out of the 9435 participants included in the study (mean age = 48.6 ± 17.6 years), 65% were in the middle tertile of the MD score. Participants who were married, employed, of a high-socioeconomic level, nonsmokers, educated and had a healthy body mass index (BMI) and waist circumference were more likely to have higher adherence levels to the MD, which was associated with lower diastolic blood pressure (p < 0.05). Multivariate logistic regression analysis showed that, even after accounting for all possible confounders, higher adherence to the MD was associated with lower risk of dyslipidaemia, OR = 1.06 (1.01-1.10). In conclusion, this analysis is the first to assess adherence to the MD on a national level. Our results indicated that MD adherence may contribute to reducing the prevalence of dyslipidaemia, cerebrovascular disease and elevated blood pressure in a multi-ethnic, non-Mediterranean country.

Consumer experiences of a healthier drinks initiative at a secure residential rehabilitation facility - a cross-sectional study.

OBJECTIVE: The objective of this study was to investigate whether consumers living with severe mental illness (SMI) receiving treatment in a secure residential rehabilitation facility considered their physical health and if limiting sugar-sweetened beverages (SSB) at facility outlets influenced dietary behaviours and knowledge. METHOD: Consumers were consulted pre-implementation and outlets (vending machines and kiosks) audited pre- and post-limiting SSB. Surveys were administered six months post-implementation with 26 surveys included in analysis. Comments from open-ended questions were examined by thematic analysis and descriptive statistics calculated for knowledge and behaviours. RESULTS: Physical health was important to most participants (96%, n = 25) and 46% (n = 11) stated beverage changes prompted consideration of their health. Many noticed beverage changes on-site (81%, n = 21), reported on-site purchases at least once-weekly (62%, n = 16) and usual beverage purchases were 'healthier' (65%, n = 17). Only 31% (n = 8) modified choices when off-site. One global theme emerged from qualitative analysis - good physical health and wellbeing is important to this cohort. CONCLUSION: Reduced availability of SSB is acceptable to many consumers; however, healthier choices in a supportive environment did not translate to behaviour change off-site. As most participants regarded physical health important, expanding the initiative within a comprehensive lifestyle strategy may facilitate sustained behaviour change and should be investigated.