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Background: Dietary risk factors are the leading cause of death globally and in New Zealand (NZ). Processed packaged foods are prevalent in the food supply and contribute excess amounts of sodium, saturated fat, and sugar in diets. Improving the nutritional quality of these foods has the potential to reduce population chronic disease risk. We aimed to evaluate the healthiness using the Australasian Health Star Rating (HSR, from 0.5 to 5 stars, with 5 being the healthiest) and nutrient composition (sodium, saturated fat, and total sugar) of packaged products manufactured by the largest NZ-based food and beverage companies in NZ 2015-2019. This analysis relates to a larger study evaluating structured engagement with food companies to improve nutrition-related policies and actions., Methods: Data was sourced from Nutritrack, a NZ-branded supermarket-sourced food composition database. The largest NZ-based companies from annual retail sales revenue (n = 35) were identified using 2019 Euromonitor data. All relevant products of the selected companies were extracted for analysis. Products included totalled 17,795 with a yearly range of 3462-3672 products. The primary outcome was a nutrient profile score estimated using HSR. Healthiness was defined as ≥ 3.5 stars. Secondary outcomes were sodium, total sugar, and saturated fat per 100 g/100 mL. All outcomes were assessed overall, by food company, and food category. Change over time was tested using linear mixed models, adjusting for major food categories and cluster effects of food companies controlling for multiple comparisons. Model-adjusted mean differences between years were estimated with 95% confidence intervals., Results: There was a small statistically significant increase in mean HSR between 2015 and 2019 (0.08 [0.15,0.01], p = 0.024). Mean total sugar content decreased over the same period (0.78 g/100 g [0.08,1.47], p = 0.020), but there were no significant changes in mean sodium or saturated fat contents. Seven of the 13 categories showed small increases in mean HSR (0.1-0.2). Most categories (9/13) exhibited a reduction in mean total sugar content., Conclusions: Between 2015 and 2019, there were slight improvements in the nutritional quality of selected packaged foods and drinks in NZ. Much more substantive changes are needed to address the health-related burden of unhealthy diets, supported by stronger government action and less reliance on voluntary industry initiatives., (© 2024. The Author(s).)

Strategies to reduce sodium concentrations in packaged foods are effective and cost-effective approaches to reducing the burden of disease attributable to high sodium intakes. This review aimed to comprehensively describe, and explore characteristics of, national strategies to reduce sodium concentrations in packaged foods, and assess progress toward achieving national goals. A secondary aim was to understand the number, type, and variation of food category sodium targets set by countries compared with WHO global sodium benchmarks. National sodium reduction reformulation strategies were identified from a search of peer-reviewed and gray literature up to December 2019 supplemented by verified information from key contacts and experts up to December 2020. Key characteristics of countries' strategies were extracted, synthesized, and descriptively analyzed, including details of reformulation strategies and evaluation data. Country targets were mapped to the WHO global sodium benchmarks, and the number and variation of country sodium targets by WHO food categories were determined. Sixty-two countries had reformulation strategies to reduce sodium in packaged foods, and 19 countries had evaluated their reformulation strategies. Forty-three countries had sodium targets, which varied in type of targets (maximum sodium concentration: n = 26; maximum concentration plus relative reduction/average/sales-weighted average: n = 8; relative reduction: n = 7; average: n = 2), number of food category targets (range: n = 1 to 150), and regulatory approach (voluntary: n = 28; mandatory: n = 9; both: n = 6). Eight of 34 countries mapped to the WHO benchmarks had targets for just 1 specified food category (bread products). One-third of all countries were implementing national strategies to reduce sodium concentrations in packaged foods including establishing targets and/or processes for industry engagement. This review determined that there is scope to improve most countries' strategies. There has been limited progress in implementing and evaluating strategies between 2014 and 2019, and regional and income-level disparities persist. The WHO global sodium benchmarks present an important opportunity to accelerate reformulation action globally., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Aim: To assess adoption of the voluntary National Healthy Food and Drink Policy (NHFDP) and the alignment of individual institutional healthy food and drink policies with the NHFDP., Method: All 20 district health boards (DHBs) and two national government agencies participated. Policies of those organisations that had not fully adopted the NHFDP were assessed across three domains: nutrition standards; promotion of a healthy food and beverages environment; and policy communication, implementation and evaluation. Three weighted domain scores out of 10, and a total score out of 30 were calculated., Results: Nine of the 22 organisations reported adopting the NHFDP in full. Of the remaining 13, six referred to the NHFDP when developing their institutional policy and three were working toward full adoption of the NHFDP. Mean scores (SD) were 8.7 (1.0), 6.1 (2.6) and 3.8 (2.2) for the three domains, and 18.6 (4.8) in total. Most individual institutional policies were not as comprehensive as the NHFDP. However, some contained stricter/additional clauses that would be useful to incorporate into the NHFDP., Conclusion: Since a similar policy analysis in 2018, most DHBs have adopted the NHFDP and/or strengthened their own nutrition policies. Regional inconsistency remains and a uniform mandatory NHFDP should be implemented that incorporates improvements identified in individual institutional policies., Competing Interests: Four authors (Cliona Ni Mhurchu, Magda Rosin, Stephanie Shen and Bruce Kidd) are members of The National DHB Food and Drink Environments Network. The Network had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors declare they have no conflict of interests., (© PMA.)

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.

Objective: To examine the effects of health-related food taxes on substitution and complementary purchases within food groups, including from unhealthier to healthier alternatives and between brands., Methods: We used data from a virtual supermarket experiment with data from 4,259 shopping events linked to varying price sets. Substitution or complementary effects within six frequently purchased food categories were analyzed. Products' own- and cross-price elasticities were analyzed using Almost Ideal Demand System models., Results: Overall, 37.5% of cross-price elasticities were significant (p < 0.05) and included values greater than 0.10. Supplementary and complementary effects were particularly found in the dairy, meats and snacks categories. For example, a 1% increase in the price of high saturated fat dairy was associated with a 0.18% (SE 0.06%) increase in purchases of low saturated fat dairy. For name- and home-brand products, significant substitution effects were found in 50% (n = 3) of cases, but only in one case this was above the 0.10 threshold., Conclusions/policy Implications: Given the relatively low own-price elasticities and the limited substitution and complementary effects, relatively high taxes are needed to substantively increase healthy food purchases at the population level., Trial Registration: This study included secondary analyses; the original trial was registered in the Australian New Zealand Clinical Trials Registry ACTRN12616000122459 ., (© 2021. The Author(s).)

Background: Childhood obesity is a major public health issue. The increase in the consumption of foods with poor nutritional value, such as processed foods, contributes to this. Breakfast cereals are often advertised as a healthy way to start the day, but the healthiness of these products varies greatly., Objective: Our main objective was to gather information about the nutritional characteristics of ready-to-eat breakfast cereals in Sweden and to investigate the healthiness of products targeted at children compared to other cereals by use of the FoodSwitch platform. A secondary objective was to evaluate the alignment between the Keyhole symbol and the Health Star Rating., Methods: The FoodSwitch app is a mobile health (mHealth) tool used to present nutrition data and healthier alternative products to consumers. Ready-to-eat breakfast cereals from the largest Swedish grocery retailers were collected using the FoodSwitch platform. Products were defined as targeting children if they presented features addressing children on the package., Results: Overall, information on 261 ready-to-eat cereals was examined. Of this total, 8% (n=21) were targeted at children. Child-targeted cereals were higher in sugar (22.3 g/100 g vs 12.8 g/100 g, P<.001) and lower in fiber (6.2 g/100 g vs 9.8 g/100 g, P<.001) and protein (8.1 g/100 g vs 10.5 g/100 g, P<.001). Total fat (3 g/100 g vs 10.5 g/100 g, P<.001) and saturated fat (0.8 g/100 g vs 2.6 g/100 g, P<.001) were also lower. No difference was found in salt content (P=.61). Fewer child-targeted breakfast cereals displayed an on-pack Keyhole label (n=1, 5% vs n=53, 22%; P=.06), and the mean Health Star Rating value was 3.5 for child-targeted cereals compared to others (mean 3.8, P=.07). A correlation was found between the Keyhole symbol and the Health Star Rating., Conclusions: Ready-to-eat breakfast cereals targeted at children were less healthy in terms of sugar and fiber content compared to products not targeted at children. There is a need to improve the nutritional quality of child-targeted cereals., (©Antoine Mottas, Veli-Matti Lappi, Johan Sundström, Bruce Neal, Cliona Ni Mhurchu, Marie Löf, Karin Rådholm. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 22.07.2021.)

Nutrient profiling systems (NPS) are used to classify foods according to their nutritional composition. However, investigating their prospective associations with health is key to their validation. The study investigated the associations of the original Food Standards Agency (FSA)-NPS and three variants (Food Standards Australia New Zealand Nutrient Profiling Scoring Criterion (NPSC), Health Star Rating NPS and the French High Council of Public Health NPS (HCSP-NPS)), with weight status. Individual dietary indices based on each NPS at the food level were computed to characterise the dietary quality of 71 403 French individuals from the NutriNet-Santé cohort. Associations of these indices with weight gain were assessed using mixed models and with overweight and obesity risks using Cox models. Participants with a higher dietary index (reflecting lower diet nutritional quality) were more likely to have a significant increase in BMI over time (β-coefficients positive) and an increased risk of overweight (hazard ratio (HR) T3 v. T1 = 1·27 (95 % CI 1·17, 1·37)) for the HCSP-Dietary Index, followed by the original FSA-Dietary Index (HR T3 v. T1 = 1·18 (95 % CI 1·09, 1·28)), the NPSC-Dietary Index (HR T3 v. T1 = 1·14 (95 % CI 1·06, 1·24)) and the Health Star Rating-Dietary Index (HR T3 v. T1 = 1·12 (95 % CI 1·04, 1·21)). Whilst differences were small, the HCSP-Dietary Index appeared to show significantly greater association with overweight risk. Overall, these results show the validity of NPS derived from the FSA-NPS, supporting their use in public policies for chronic disease prevention.

Context: Food Balance Sheets (FBSs) are constructed by the Food and Agricultural Organization (FAO) and portray the food supply and utilization pattern of a country over time., Objective: To examine and analyse the uses of FAO-FBS data in international studies of health and nutrition, and to identify the reported strengths, limitations and reliability of FBS., Data Sources: PubMed, SCOPUS, EMBASE, Food Science and Technology Abstracts (FSTA) and Google Scholar., Data Extraction: Data extracted were author, year of publication, country/countries of the study, aim, study design, analysis, data collected, data sources and outcomes. Additional relevant information (e.g. strengths and limitations of the FBS), were also included. The bibliographies of all included studies were further searched, and any potentially relevant studies retrieved and assessed., Data Analysis: 119 eligible studies (all study designs) published from the earliest available to the end of April, 2016 were collated into five categories of use: within-country analysis of food availability, nutrient availability and/or dietary trends (n = 17); inter-country, regional or global comparison of food groups, nutrient availability and/or dietary trends (n = 45); comparison of FBS with other national sources of dietary data (n = 7); association between FBS dietary factors and mortality or health outcomes (n = 45); and modelling studies (n = 5)., Conclusion: Studies indicate that FBS are useful for international comparison and analysis of trends over time, as they are standardized and updated regularly. FBS data are more reliable when averaged over several years; when results are reported as nutrient densities, trends, and percentage of energy or ratios, rather than absolute values. Also, users should be aware that the quality of FBS data depends on the reliability of national input data. The FBS is a vital source of global food composition data and is valuable for epidemiological studies when reported and analysed appropriately., (© The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: The primary objective of this study was to determine the effect of a mobile health (mHealth) intervention on the wellbeing of Pasifika peoples, and to explore factors associated with Pasifika wellbeing., Methods: The OL@-OR@ mHealth programme was a co-designed smartphone app. Culturally relevant data was collected to examine holistic health and wellbeing status, at baseline, and at 12 weeks (end of the trial). The concept of wellbeing was examined as part of a two-arm, cluster randomised trial, using only the Pasifika data: 389 (of 726) Pasifika adults were randomised to receive the mHealth intervention, while 405 (of 725) Pasifika adults were randomised to receive a control version of the intervention. Culturally relevant data was collected to examine holistic health and wellbeing status, at baseline, and at 12 weeks (end of the trial). The intervention effects and the association of demographic and behavioural relationships with wellbeing, was examined using logistic regression analyses., Results: Relative to baseline, there were significant differences between the intervention and control groups for the 'family/community' wellbeing, at the end of the 12-week trial. There were no significant differences observed for all other wellbeing domains for both groups. Based on our multivariate regression analyses, education and acculturation (assimilation and marginalisation) were identified as positively strong factors associated to Pasifika 'family and community' wellbeing., Conclusion: Our study provides new insights on how Pasifika peoples' characteristics and behaviours align to wellbeing. Our findings point to 'family and community' as being the most important wellbeing factor for Pasifika peoples., Competing Interests: Nil.

Background: The Australian federal government will soon release voluntary sodium reduction targets for 30 packaged food categories through the Healthy Food Partnership. Previous assessments of voluntary targets show variable industry engagement, and little is known about the extent that major food companies and their products contribute to dietary sodium purchases among Australian households., Methods: The aim of this cross-sectional study was to identify the relative contribution that food companies and their products made to Australian household sodium purchases in 2018, and to examine differences in sodium purchases by household income level. We used 1 year of grocery purchase data from a nationally representative consumer panel of Australian households who reported their grocery purchases (the Nielsen Homescan panel), combined with database that contains product-specific sodium content for packaged foods and beverages (FoodSwitch). The top food companies and food categories were ranked according to their contribution to household sodium purchases. Differences in per capita sodium purchases by income levels were assessed by 1-factor ANOVA. All analyses were modelled to the Australian population in 2018 using sample weights., Results: Sodium data were available from 7188 households who purchased 26,728 unique products and purchased just under 7.5 million food product units. Out of 1329 food companies, the top 10 accounted for 35% of unique products and contributed to 58% of all sodium purchased from packaged foods and beverages. The top three companies were grocery food retailers each contributing 12-15% of sodium purchases from sales of their private label products, particularly processed meat, cheese and bread. Out of the 67 food categories, the top 10 accounted for 73% of sodium purchased, particularly driven by purchases of processed meat (14%), bread (12%) and sauces (11%). Low-income Australian households purchased significantly more sodium from packaged products than high-income households per capita (452 mg/d, 95%CI: 363-540 mg/d, P < 0.001)., Conclusions: A small number of food companies and food categories account for most of the dietary sodium purchased by Australian households. Prioritizing government engagement with these groups could deliver a large reduction in population sodium intake.

Background: Food taxes and subsidies are one intervention to address poor diets. Price elasticity (PE) matrices are commonly used to model the change in food purchasing. Usually a PE matrix is generated in one setting then applied to another setting with differing starting consumptions and prices of foods. This violates econometric assumptions resulting in likely mis-estimation of total food consumption. In this paper we demonstrate this problem, canvass possible options for rescaling all consumption after applying a PE matrix, and illustrate the use of a total food expenditure elasticity (TFEe; the expenditure elasticity for all food combined given the policy-induced change in the total price of food). We use case studies of: NZ$2 per 100g saturated fat (SAFA) tax, NZ$0.4 per 100g sugar tax, and a 20% fruit and vegetable (F&V) subsidy., Methods: We estimated changes in food purchasing using a NZ PE matrix applied conventionally, and then with TFEe adjustment. Impacts were quantified for pre- to post-policy changes in total food expenditure and health adjusted life years (HALYs) for the total NZ population alive in 2011 over the rest of their lifetime using a multistate lifetable model., Results: Two NZ studies gave TFEe's of 0.68 and 0.83, with international estimates ranging from 0.46 to 0.90 (except a UK outlier of 0.04). Without TFEe adjustment, total food expenditure decreased with the tax policies and increased with the F&V subsidy-implausible directions of shift given economic theory and the external TFEe estimates. After TFEe adjustment, HALY gains reduced by a third to a half for the two taxes and reversed from an apparent health loss to a health gain for the F&V subsidy. With TFEe adjustment, HALY gains (in 1000's) were: 1,805 (95% uncertainty interval 1,337 to 2,340) for the SAFA tax; 1,671 (1,220 to 2,269) for the sugar tax; and 953 (453 to 1,308) for the F&V subsidy., Conclusions: If PE matrices are applied in settings beyond where they were derived, additional scaling is likely required. We suggest that the TFEe is a useful scalar, but we also encourage other researchers to examine this issue and propose alternative options., Competing Interests: The authors have declared that no competing interests exist.

Background: Reducing sugar in packaged foods and beverages could help protect children's future health. Clear methods for the development of feasible yet impactful sugar reduction program targets are needed., Objectives: To outline methods for the development of program targets that would reduce, by 20%, the total sugar content of packaged foods and beverages commonly consumed by children. New Zealand (NZ) is used as a case study., Methods: Sugar content and pack size targets were developed using a 6-step process informed by the UK sugar and salt reduction programs. Food groups contributing ≥2% to children's total sugar intake were identified using national dietary survey data. Consumption volume, sugar content, and pack size were obtained from household panel data linked with a packaged food composition database. Category-specific targets were set as 20% reductions in sales-weighted means adjusted for feasibility, i.e., ∼1/3 of products already meeting the target, and alignment with existing, relevant targets., Results: Twenty-two food groups were identified as major contributors to NZ children's total sugar intake. Mean reductions required in sugar content and pack size to meet the targets were 5.2 g  per 100 g/mL (26%) and 61.2 g/mL/pack (23%), respectively. The percentage of products already meeting the sugar targets ranged from 14% for electrolyte drinks and flavored dairy milk to 50% for cereal bars, and for pack size targets compliance ranged from 32% for chocolate confectionary to 62% for fruit juices and drinks. Estimated reductions in annual household sugar purchases if the sugar and pack size targets were met were 1459 g (23%) and 286 g (6%), respectively., Conclusions: Methods for the development of sugar and pack size reduction targets are presented, providing a robust, step-by-step process for countries to follow. The results of the case study provide a suggested benchmark for a potential national sugar reduction program in NZ., (Copyright © The Author(s) 2019.)

Objective: The Health Star Rating (HSR) is a voluntary front-of-pack nutrition labelling system that rates products from ½ to 5 stars (five being healthiest). The Chilean Warning Label system displays warnings on foods high in sugar, saturated fat, sodium, or energy. We aimed to evaluate alignment between the systems., Methods: New Zealand packaged products (n=13,868) were classified according to the two systems. Alignment was assessed by cross-checking the number of products meeting the criteria for warnings against star ratings. Products with no warnings but an HSR <2, or with >1 warning but an HSR of ≥3.5 were considered outliers., Results: Two-thirds of products met the criteria for at least one warning. There was a significant positive relationship between the number of warnings and mean HSR: 0 warnings = HSR 3.77±.0166 (p<0.001), 1 warning = HSR 2.70±.0206 (p<0.001) and >1 warning = HSR 2.00±.0160 (p<0.001). The systems were non-aligned for 1,117 products (8%)., Conclusion: HSR and the Chilean Warning Label systems are broadly aligned. Non-alignment is due to the Chilean system restricting warnings to foods containing added ingredients and HSR awarding points for positive components. Implications for public health: These results could be helpful in informing improvements to the HSR system., (© 2019 The Authors.)

Price is a key determinant of food choice, particularly for low-income households who may be more sensitive to price-lowering strategies such as price promotions and generic/retailer-owned brands. Price-lowering strategies may therefore represent important policy targets to improve population nutrition and reduce inequities. This study aimed to describe household purchasing patterns of price promoted and generic branded foods and beverages in New Zealand (2016-2017). One year of grocery purchase data from a national consumer research panel in New Zealand (n = 1778 households) were analysed. Purchases were classified by processing level and food type. Linear mixed models were fitted to estimate the mean proportion of annual household purchases (unique items and volumes (kg/L)) that were price promoted or generic branded (overall and by food category), and to assess whether purchasing patterns were modified by income level. On average, price promoted products constituted 50% (95%CIs; 49,51) of all unique annual household grocery items purchased. Fifty-nine percent (95%CIs; 58,60) of processed, 55% (95%CIs; 54,56) of ultra-processed, 45% (95%CIs; 44,46) of unprocessed and 45% (95%CIs; 44,46) of ingredient purchases were price promoted. By volume, the proportion of purchases that were price promoted was highest for meat (65%[95%CIs; 64,66]), sugar-sweetened beverages (64%[95%CIs; 62,65]), dairy foods (64%[95%CIs; 63,66]), confectionary (64%[95%CIs; 63,66]), snack foods (63%[95%CIs; 61,64]), oils (61%[95%CIs; 60,62]) and non-sugar-sweetened beverages (60%[95%CIs; 58,62]), and lowest for dairy beverages (30%[95%CIs; 28,31]), sugar/honey (33%[95%CIs; 32,35]) and sauces/spreads (39%[95%CIs; 37,40]). On average, generic brands constituted 10% (95%CIs; 9,10) of all household purchases. Overall, a significantly greater proportion of purchases made by low and middle-income households were price promoted and generic branded compared to high-income households (p < 0.001 for both), a pattern generally observed across food categories. This study supports recent calls to address unhealthy food and beverage price promotions in comprehensive policy strategies aiming to improve population diets and weight., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Most evidence on health-related food taxes and subsidies relies on observational data and effects on single nutrients or foods instead of total diet. The aim of this study was to measure the effect of randomly assigned food price variations on consumer purchasing, where sets of prices emulated commonly discussed food tax and subsidy policies, including a subsidy on fruit and vegetables, a sweetened beverage tax, and taxes on foods according to sugar, sodium, and saturated fat content., Methods: In this study, adult participants (≥18 years) in New Zealand completed up to five weekly shops in a virtual supermarket. Each shopping occasion was randomly allocated to control (no change in prices) or one or more pricing options simulating the following: a fruit and vegetable subsidy (20%), a sweetened beverage tax (20% or 40%), a saturated fat tax (NZ$2 per 100 g or $4 per 100 g saturated fat), a salt tax ($0·02 per 100 mg or $0·04 per 100 mg sodium), or sugar tax ($0·40 per 100 g or $0·80 per 100 g sugar). The primary outcome was the healthiness of the total shopping basket for each weekly shop (% of total unit food items defined as healthy). Low and high price change options were combined in analyses (eg, results for a saturated fat tax are an average of $2 per 100 g or $4 per 100 g)., Findings: Between Feb 1, and Dec 1, 2016, we randomly assigned 1132 shoppers, of whom 1038 (91·7%) completed at least one shop and 743 (71·6%) completed all five shops. Overall, data from 4258 shops were included in the analysis, including 645 control shops, 2545 shops where one policy was activated, and 1068 shops with two (or more) policies activated. In the control condition, 67·90% (SD 13·01) of food purchases were classified as healthy. Three of the five policies increased this proportion by a small, but significant amount (saturated fat tax mean absolute difference 1·77%, 95% CI 1·03 to 2·52, p<0·0001; sugar tax 1·09%, 0·26 to 1·91, p=0·0099; and salt tax 1·31%, 0·50 to 2·13, p=0·0016). The sweetened beverage tax and fruit and vegetable subsidy resulted in non-significant increases of 0·18% (95% CI -0·49 to 0·85, p=0·60) and 0·41% (-0·26 to 1·07, p=0·23), respectively. Both the saturated fat tax and salt tax resulted in the following important substitution effects: an increase in fruit and vegetable purchases as a percentage by weight of all food purchases (saturated fat tax 4·0%, 0·9 to 7·1; salt tax 4·3%, 0·9 to 7·7); but also an increase in sugar as a percentage of total energy (saturated fat tax 5·0%, 2·1 to 7·9; salt tax 3·2%, 0·0 to 6·5). Interaction terms for combined policies were mostly non-significant, consistent with additive effects of policy combinations., Interpretation: Price changes representing saturated fat, sugar, and salt taxes increased total healthy food purchases. As we observed important substitution effects, a combination of different tax and subsidy policies might be the most effective way to improve diets and decrease diet-related chronic diseases., Funding: Health Research Council of New Zealand., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The use of lifelogging device in dietary assessments can reduce misreporting and underreporting, which are common in the previous studies conventional methods. We performed the first study in Chinese children (primary school Grade 4) that applied the wearable cameras in assisting dietary recall. Children (n = 52) wore the wearable cameras (Narrative Clip 2) for seven consecutive days, during which they completed a 3-day 24-h dietary recall at home. Then children modified their dietary recalls at school by reviewing the photos taken by the wearable camera at school, with the assistance of the investigator, and generated the camera-assisted 24-h dietary recalls. Compared with camera-assisted dietary recalls, 8% (n = 160) and 1% (n = 11) of food items were underreported (i.e. not reported at all) and misreported (i.e. reported in an incorrect amount) by dietary recalls without camera-assistance, respectively. Dietary recalls without camera assistance underestimated daily energy intake by 149 ± 182 kcal/d (8%) in comparison to the camera-assisted dietary recalls. Foods consumed on the snacking occasions (40%) were more likely to be underreported than those consumed at main meals (P < 0.001). Beverages (37%), fruits (30%), snacks and desserts (16%) were foods most likely to be inaccurately reported. Children were satisfied with the wearable cameras, with a median score 5.0 (IQR: 5.0-5.0) for most features. Wearable cameras hold promise for improving accuracy of dietary intake assessment in children, providing rich objective information on dietary behaviours, and received high level of satisfaction and compliance of the users. Our results suggest that the accuracy of dietary recall among Chinse school-aged children could be improved by wearable camera, especially avoiding underreporting in the snacking occasions., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The obesity rate in New Zealand is one of the highest worldwide (31%), with highest rates among Māori (47%) and Pasifika (67%). Codesign was used to develop a culturally tailored, behavior change mHealth intervention for Māori and Pasifika in New Zealand. The purpose of this article is to provide an overview of the codesign methods and processes and describe how these were used to inform and build a theory-driven approach to the selection of behavioral determinants and change techniques. The codesign approach in this study was based on a partnership between Māori and Pasifika partners and an academic research team. This involved working with communities on opportunity identification, elucidation of needs and desires, knowledge generation, envisaging the mHealth tool, and prototype testing. Models of Māori and Pasifika holistic well-being and health promotion were the basis for identifying key content modules and were applied to relevant determinants of behavior change and theoretically based behavior change techniques from the Theoretical Domains Framework and Behavior Change Taxonomy, respectively. Three key content modules were identified: physical activity, family/whānau [extended family], and healthy eating. Other important themes included mental well-being/stress, connecting, motivation/support, and health literacy. Relevant behavioral determinants were selected, and 17 change techniques were mapped to these determinants. Community partners established that a smartphone app was the optimal vehicle for the intervention. Both Māori and Pasifika versions of the app were developed to ensure features and functionalities were culturally tailored and appealing to users. Codesign enabled and empowered users to tailor the intervention to their cultural needs. By using codesign and applying both ethnic-specific and Western theoretical frameworks of health and behavior change, the mHealth intervention is both evidence based and culturally tailored., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Aims: This study explored children's awareness of and engagement with food marketing, and their views on action to address it., Methods: A purposeful sample of 33 children (11-13 years) from the Wellington region of New Zealand were interviewed., Results: Children were knowledgeable about food marketing, although most were not aware of the extent to which they were exposed. Children did not distinguish 'marketing to children' from other marketing. According to the children, they were frequently exposed to food marketing, and persuaded, against their better judgement, to purchase food they knew to be harmful to their health. As many children recognised the unhealthy nature of the food marketed to them, they agreed they would take action to reduce junk food marketing if they were Prime Minister for a day. Interventions included making food marketing honest, providing nutrition information, removing billboards and increasing the promotion of healthy food., Conclusions: These findings suggest children's exposure to junk food marketing may cause them physical, mental and moral harm, in direct contradiction of the New Zealand self-regulatory code for marketing. The children's views align with the World Health Assembly's recent decision to endorse initiatives to end childhood obesity, including restricting marketing of unhealthy foods., Competing Interests: Dr Ni Mhurchu and Dr Chambers report grants from Health Research Council of New Zealand during the conduct of the study.

Sugar-sweetened beverage (SSB) intake is associated with tooth decay, obesity and diabetes. We aimed to model the health and cost impact of reducing the serving size of all single serve SSB to a maximum of 250 ml in New Zealand. A 250 ml serving size cap was modeled for all instances of single serves (<600 ml) of sugar-sweetened carbonated soft drinks, fruit drinks, carbonated energy drinks, and sports drinks in the New Zealand National Nutrition Survey intake data (2008/09). A multi-state life-table model used the change in energy intake and therefore BMI to predict the resulting health gains in quality-adjusted life-years (QALYs) and health system costs over the remaining life course of the New Zealand population alive in 2011 (N = 4.4 million, 3% discounting). The 'base case' model (no compensation for reduced energy intake) resulted in an average reduction in SSB and energy intake of 23 ml and 44 kJ (11 kcal) per day or 0.22 kg of weight modeled over two years. The total health gain and cost-savings were 82,100 QALYs (95% UI: 65100 to 101,000) and NZ$1.65 billion [b] (95% UI: 1.19 b to 2.24 b, (US$1.10 b)) over the lifespan of the cohort. QALY gains increased to 116,000 when the SSB definition was widened to include fruit juices and sweetened milks. A cap on single serve SSB could be an effective part of a suite of obesity prevention and sugar reduction interventions in high income countries., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The aim of this research was to quantify children's exposure to alcohol marketing via product packaging using wearable cameras, observing sociodemographic differences and contextual features of exposure., Method: In Wellington, New Zealand, 167 children (ages 11-13; 53% girls) wore wearable cameras for 4 consecutive days. The cameras automatically captured images approximately every 7 seconds. Image data (n = 700,000 images) were coded through content analysis to determine the extent of children's exposure to alcohol marketing via product packaging. Negative binomial regression models were used to calculate rates of exposure per day and to examine differences between groups., Results: Children were exposed to alcohol marketing via product packaging 7.7 times per day, on average. Product packaging contained limited health information and lacked defining features that could provide visual cues to children to differentiate alcohol from other commodities. No statistically significant differences by sociodemographic characteristics were detected., Conclusions: Children are frequently exposed to alcohol marketing via product packaging. Such exposure normalizes alcohol in children's environments and fails to send accurate information to children about the health risks associated with alcohol consumption. Mandatory labeling on alcohol product packaging, including prominent health warnings (text, pictorial, and graphic), or plain packaging, provides governments an opportunity to substantially reduce children's overall exposure to alcohol marketing and potentially increase children's awareness of the risks associated with alcohol consumption.

Background and Aim: Neighbourhood alcohol availability has been associated with alcohol consumption by children, despite children rarely acquiring alcohol from retailers. This study explores one potential reason for this finding, by evaluating the relationships between neighbourhood alcohol availability and children's actual exposure to alcohol marketing., Method: Wearable cameras and GPS devices were worn by 167 children (aged 11-13 y) over a four-day period. Image and GPS data were linked and compared to known alcohol availability data., Results: Off-licence retailer availability and ethnicity were positively associated with children's exposure to marketing in both residential and school neighbourhoods., Conclusion: Neighbourhood off-licence alcohol retailers are associated with increased childhood exposure to alcohol marketing., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The Health Star Rating (HSR) system is a voluntary front-of-pack labelling (FoPL) initiative endorsed by the Australian government in 2014. This study examines the impact of the HSR system on pre-packaged food reformulation measured by changes in energy density between products with and without HSR. The cost-effectiveness of the HSR system was modelled using a proportional multi-state life table Markov model for the 2010 Australian population. We evaluated scenarios in which the HSR system was implemented on a voluntary and mandatory basis (i.e., HSR uptake across 6.7% and 100% of applicable products, respectively). The main outcomes were health-adjusted life years (HALYs), net costs, and incremental cost-effectiveness ratios (ICERs). These were calculated with accompanying 95% uncertainty intervals (95% UI). The model predicted that HSR-attributable reformulation leads to small changes [corrected] in mean population energy intake (voluntary: -0.98 kJ/day; mandatory: -11.81 kJ/day). [corrected]. These are likely to result in changes in mean body weight (voluntary: -0.01 kg [95% UI: -0.012 to -0.006]; mandatory: -0.11 kg [95% UI: -0.14 to -0.07, and HALYs gained [corrected] (voluntary: 4207 HALYs gained [corrected] [95% UI: 2438 to 6081]; mandatory: 49,949 HALYs gained [95% UI: 29,291 to 72,153]). The HSR system [corrected] could be considered cost-effective relative to a willingness-to-pay threshold of A$50,000 per HALY (incremental cost effectiveness ratio for voluntary: [corrected] A$1728 per HALY [95% UI: dominant to 10,445] and mandatory: A$4752 per HALY [95% UI: dominant to 16,236]).

Interpretive, front-of-pack (FOP) nutrition labels may encourage reformulation of packaged foods. We aimed to evaluate the effects of the Health Star Rating (HSR), a new voluntary interpretive FOP labelling system, on food reformulation in New Zealand. Annual surveys of packaged food and beverage labelling and composition were undertaken in supermarkets before and after adoption of HSR i.e., 2014 to 2016. Outcomes assessed were HSR uptake by food group star ratings of products displaying a HSR label; nutritional composition of products displaying HSR compared with non-HSR products; and the composition of products displaying HSR labels in 2016 compared with their composition prior to introduction of HSR. In 2016, two years after adoption of the voluntary system, 5.3% of packaged food and beverage products surveyed ( n = 807/15,357) displayed HSR labels. The highest rates of uptake were for cereals, convenience foods, packaged fruit and vegetables, sauces and spreads, and 'Other' products (predominantly breakfast beverages). Products displaying HSR labels had higher energy density but had significantly lower mean saturated fat, total sugar and sodium, and higher fibre, contents than non-HSR products (all p -values < 0.001). Small but statistically significant changes were observed in mean energy density (-29 KJ/100 g, p = 0.002), sodium (-49 mg/100 g, p = 0.03) and fibre (+0.5 g/100 g, p = 0.001) contents of HSR-labelled products compared with their composition prior to adoption of HSR. Reformulation of HSR-labelled products was greater than that of non-HSR-labelled products over the same period, e.g., energy reduction in HSR products was greater than in non-HSR products (-1.5% versus -0.4%), and sodium content of HSR products decreased by 4.6% while that of non-HSR products increased by 3.1%. We conclude that roll-out of the voluntary HSR labelling system is driving healthier reformulation of some products. Greater uptake across the full food supply should improve population diets.

Objectives: Delivery of interventions via smartphone is a relatively new initiative in public health, and limited evidence exists regarding optimal strategies for recruitment. We describe the effectiveness of approaches used to recruit participants to a smartphone-enabled nutrition intervention trial., Methods: Internet and social media advertising, mainstream media advertising and research team networks were used to recruit New Zealand adults to a fully automated smartphone-delivered nutrition labelling trial (no face-to-face visits were required). Recruitment of Māori and Pacific participants was a key focus and ethically relevant recruitment materials and approaches were used where possible. The effectiveness of recruitment strategies was evaluated using Google Analytics, monitoring of study website registrations and randomisations, and self-reported participant data. The cost of the various strategies and associations with participant demographics were assessed., Results: Over a period of 13 months, there were 2448 registrations on the study website, and 1357 eligible individuals were randomised into the study (55%). Facebook campaigns were the most successful recruitment strategy overall (43% of all randomised participants) and for all ethnic groups (Māori 44%, Pacific 44% and other 43%). Significant associations were observed between recruitment strategy and age (p<0.001), household size (p<0.001), ethnicity (p<0.001), gender (p=0.005) and interest in healthy eating (p=0.022). Facebook campaigns resulted in the highest absolute numbers of study registrations and randomisations (966 and 584, respectively). Network strategies and Facebook campaigns cost least per randomised participant (NZ$4 and NZ$5, respectively), whereas radio advertising costs most (NZ$179 per participant)., Conclusion: Internet and social media advertising were the most effective and least costly approaches to recruiting participants to a smartphone-delivered trial. These approaches also reached diverse ethnic groups. However, more culturally appropriate recruitment strategies are likely to be necessary in studies where large numbers of participants from specific ethnic groups are sought., Trial Registration: ACTRN12614000644662; Post-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In-store availability of healthy and unhealthy foods may influence consumer purchases. Methods used to measure food availability, however, vary widely. A simple, valid, and reliable indicator to collect comparable data on in-store food availability is needed., Methods: Cumulative linear shelf length of and variety within 22 healthy and 28 unhealthy food groups, determined based on a comparison of three nutrient profiling systems, were measured in 15 New Zealand supermarkets. Inter-rater reliability was tested in one supermarket by a second researcher. The construct validity of five simple indicators of relative availability of healthy versus unhealthy foods was assessed against this 'gold standard'., Results: Cumulative linear shelf length was a more sensitive and feasible measure of food availability than variety. Four out of five shelf length ratio indicators were significantly associated with the gold standard (ρ = 0.70-0.75). Based on a non-significant difference from the 'gold standard' (d = 0.053 ± 0.040) and feasibility, the ratio of cumulative linear shelf length of fresh and frozen fruits and vegetables versus soft and energy drinks, crisps and snacks, sweet biscuits and confectionery performed best for use in New Zealand supermarkets., Conclusions: Four out of the five shelf length ratio indicators of the relative availability of healthy versus unhealthy foods in-store tested could be used for future research and monitoring, but additional validation studies in other settings and countries are recommended. Consistent use of those shelf length ratio indicators could enhance comparability of supermarket food availability between studies, and help inform policies to create healthy consumer food retail environments.

Reducing the exposure of children and young people to the marketing of unhealthy foods is a core strategy for reducing the high overweight and obesity prevalence in this population. The Advertising Standards Authority (ASA) has recently reviewed its self-regulatory codes and proposed a revised single code on advertising to children. This article evaluates the proposed code against eight criteria for an effective code, which were included in a submission to the ASA review process from over 70 New Zealand health professors. The evaluation found that the proposed code largely represents no change or uncertain change from the existing codes, and cannot be expected to provide substantial protection for children and young people from the marketing of unhealthy foods. Government regulations will be needed to achieve this important outcome., Competing Interests: Nil.

Background: Evidence is mounting that price discounts can be effective in improving diet. This study examined the effectiveness of a 20% price discount on food and drink purchases with and without consumer education in remote Indigenous Australia., Methods: A 20% discount on fruit, vegetables, water, and artificially sweetened soft drinks was applied for 24 weeks in 20 communities in remote Indigenous Australia where the community store was managed by the Arnhem Land Progress Aboriginal Corporation (ALPA) or Outback Stores (OBS) in a stepped-wedge randomised trial. Communities were randomly allocated to a fixed framework of five sets of four stratified by store association; ten stores (two in each set) were randomly assigned to receive consumer education. A store from each of the ALPA and OBS store groups (contained in separate opaque envelopes) was selected, and stores in turn continued to be consecutively allocated to the fixed store set framework, starting with the first store slot in the first store set, until all stores had been allocated. The effect of the discount on the weight of fruit and vegetables purchased (the primary endpoint) was assessed using weekly store sales data and mixed models per protocol. We did sensitivity analyses by repeating the analyses with the outliers included and repeating the analyses for the primary outcome measure removing each store one at a time. This trial was registered with Australian New Zealand Clinical Trials Registry, number ACTRN12613000694718., Findings: Weekly store sales data on all food and drink products sold in 20 stores were collected from July 1, 2012, to Dec 28, 2014. Price discount alone was associated with a 12·7% (95% CI 4·1-22·1) increase in purchases in grams of fruit and vegetables combined (primary outcome), and a 19·8% (6·2-35·1) increase post discount (after vs before); an effect of 12 g and 18 g per capita per day. Sensitivity analyses did not modify the results for the primary outcome measure., Interpretation: A 20% discount can only increase fruit and vegetable purchases to help protect against obesity and diet related disease to a certain extent. Large discounts might have a greater impact than small discounts. Creative merchandising approaches to consumer education could also be considered alongside fiscal interventions to achieve marked improvements in diet., Funding: Australian National Health and Medical Research Council., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)

Aim: Promotion of unhealthy foods and drinks is a significant, modifiable risk factor for child obesity and diet-related non-communicable diseases. We compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model, to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages., Methods: 13,066 packaged foods from the 2014 New Zealand Nutritrack database were classified as 'restricted' or 'not restricted' as per the WHO model; 'everyday/sometimes' or 'occasional' as per the FBCS model; and '<3.5 stars' or '≥3.5 stars' as per the HSR model. The proportion and types of packaged foods that met the criteria for all three systems or none of the systems, and the types of food products classified as 'restricted' under the WHO model but classified as 'everyday/sometimes' (FBCS model) or as having >3.5 stars, were determined., Results: Under any of the three nutrient profiling systems, approximately one-third (29-39%) of New Zealand packaged foods would be permitted to be marketed to children. The WHO Model would permit marketing of 29% of products; the HSR system would permit 36%; and the FBCS system would permit 39%. The WHO Model restricts marketing of unhealthy foods more effectively than the other two systems. The HSR and FBCS systems would permit marketing of a number of food products of concern, particularly high-sugar breakfast cereals, fruit juices and ready meals., Conclusion: The WHO Regional Office for Europe Nutrient Profiling Model should underpin the Advertising Standards Authority revised Children's Code for Advertising Food. The effectiveness of the new Code in reducing New Zealand children's exposure to marketing of unhealthy foods and drinks should be subject to evaluation by an independent body.

Objective: Pricing strategies are a promising approach for promoting healthier dietary choices. However, robust evidence of the cost-effectiveness of pricing manipulations on dietary behaviour is limited. We aimed to assess the cost-effectiveness of a 20% price reduction on fruits and vegetables and a combined skills-based behaviour change and price reduction intervention., Design and Methods: Cost-effectiveness analysis from a societal perspective was undertaken for the randomized controlled trial Supermarket Healthy Eating for Life (SHELf). Female shoppers in Melbourne, Australia were randomized to: (1) skill-building (n = 160); (2) price reductions (n = 161); (3) combined skill-building and price reduction (n = 161); or (4) control group (n = 161). The intervention was implemented for three months followed by a six month follow-up. Costs were measured in 2012 Australian dollars. Fruit and vegetable purchasing and consumption were measured in grams/week., Results: At three months, compared to control participants, price reduction participants increased vegetable purchases by 233 g/week (95% CI 4 to 462, p = 0.046) and fruit purchases by 364 g/week (95% CI 95 to 633, p = 0.008). Participants in the combined group purchased 280 g/week more fruits (95% CI 27 to 533, p = 0.03) than participants in the control group. Increases were not maintained six-month post intervention. No effect was noticed in the skill-building group. Compared to the control group, the price reduction intervention cost an additional A$2.3 per increased serving of vegetables purchased per week or an additional A$3 per increased serving of fruit purchased per week. The combined intervention cost an additional A$12 per increased serving of fruit purchased per week compared to the control group., Conclusions: A 20% discount on fruits and vegetables was effective in promoting overall fruit and vegetable purchases during the period the discount was active and may be cost-effective. The price discount program gave better value for money than the combined price reduction and skill-building intervention. The SHELf trial is registered with Current Controlled Trials Registration ISRCTN39432901., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Dietary salt reduction is included in the top five priority actions for non-communicable disease control internationally. We therefore aimed to identify health gain and cost impacts of achieving a national target for sodium reduction, along with component targets in different food groups., Methods: We used an established dietary sodium intervention model to study 10 interventions to achieve sodium reduction targets. The 2011 New Zealand (NZ) adult population (2.3 million aged 35+ years) was simulated over the remainder of their lifetime in a Markov model with a 3 % discount rate., Results: Achieving an overall 35 % reduction in dietary salt intake via implementation of mandatory maximum levels of sodium in packaged foods along with reduced sodium from fast foods/restaurant food and discretionary intake (the "full target"), was estimated to gain 235,000 QALYs over the lifetime of the cohort (95 % uncertainty interval [UI]: 176,000 to 298,000). For specific target components the range was from 122,000 QALYs gained (for the packaged foods target) down to the snack foods target (6100 QALYs; and representing a 34-48 % sodium reduction in such products). All ten target interventions studied were cost-saving, with the greatest costs saved for the mandatory "full target" at NZ$1260 million (US$820 million). There were relatively greater health gains per adult for men and for Māori (indigenous population)., Conclusions: This work provides modeling-level evidence that achieving dietary sodium reduction targets (including specific food category targets) could generate large health gains and cost savings for a national health sector. Demographic groups with the highest cardiovascular disease rates stand to gain most, assisting in reducing health inequalities between sex and ethnic groups.

Background: Traffic light labelling of foods-a system that incorporates a colour-coded assessment of the level of total fat, saturated fat, sugar and salt on the front of packaged foods-has been recommended by the UK Government and is currently in use or being phased in by many UK manufacturers and retailers. This paper describes a protocol for a pilot randomised controlled trial of an intervention designed to increase the use of traffic light labelling during real-life food purchase decisions., Methods/design: The objectives of this two-arm randomised controlled pilot trial are to assess recruitment, retention and data completion rates, to generate potential effect size estimates to inform sample size calculations for the main trial and to assess the feasibility of conducting such a trial. Participants will be recruited by email from a loyalty card database of a UK supermarket chain. Eligible participants will be over 18 and regular shoppers who frequently purchase ready meals or pizzas. The intervention is informed by a review of previous interventions encouraging the use of nutrition labelling and the broader behaviour change literature. It is designed to impact on mechanisms affecting belief and behavioural intention formation as well as those associated with planning and goal setting and the adoption and maintenance of the behaviour of interest, namely traffic light label use during purchases of ready meals and pizzas. Data will be collected using electronic sales data via supermarket loyalty cards and web-based questionnaires and will be used to estimate the effect of the intervention on the nutrition profile of purchased ready meals and pizzas and the behavioural mechanisms associated with label use. Data collection will take place over 48 weeks. A process evaluation including semi-structured interviews and web analytics will be conducted to assess feasibility of a full trial., Discussion: The design of the pilot trial allows for efficient recruitment and data collection. The intervention could be generalised to a wider population if shown to be feasible in the main trial., Trial Registration: ISRCTN: ISRCTN19316955.

Decreasing population sodium intake has been identified as a "best buy" for reducing non-communicable disease. The aim of this study was to explore 10-year changes in the sodium content of New Zealand processed foods. Nutrient data for nine key food groups were collected in supermarkets in 2003 (n = 323) and 2013 (n = 885). Mean (SD) and median (min, max) sodium content were calculated by food group, year and label type (private/branded). Paired t-tests explored changes in sodium content for all products available for sale in both years (matched; n = 182). The mean (SD) sodium content of all foods was 436 (263) mg (100 g)(-1) in 2003 and 433 (304) mg (100 g)(-1) in 2013, with no significant difference in matched products over time (mean (SD) difference, -56 (122) mg (100 g)(-1), 12%; p = 0.22). The largest percentage reductions in sodium (for matched products) were observed for Breakfast Cereals (28%; -123 (125) mg (100 g)(-1)), Canned Spaghetti (15%; -76 (111) mg (100 g)(-1)) and Bread (14%; -68 (69) mg (100 g)(-1)). The reduction in sodium was greater for matched private vs. branded foods (-69 vs. -50 mg (100 g)(-1), both p < 0.001). There has been modest progress with sodium reduction in some New Zealand food categories over the past 10 years. A renewed focus across the whole food supply is needed if New Zealand is to meet its global commitment to reducing population sodium intake.

Background: Screen-based activities, such as watching television (TV), playing video games, and using computers, are common sedentary behaviors among young people and have been linked with increased energy intake and overweight. Previous home-based sedentary behaviour interventions have been limited by focusing primarily on the child, small sample sizes, and short follow-up periods. The SWITCH (Screen-Time Weight-loss Intervention Targeting Children at Home) study aimed to determine the effect of a home-based, family-delivered intervention to reduce screen-based sedentary behaviour on body composition, sedentary behaviour, physical activity, and diet over 24 weeks in overweight and obese children., Methods: A two-arm, parallel, randomized controlled trial was conducted. Children and their primary caregiver living in Auckland, New Zealand were recruited via schools, community centres, and word of mouth. The intervention, delivered over 20 weeks, consisted of a face-to-face meeting with the parent/caregiver and the child to deliver intervention content, which focused on training and educating them to use a wide range of strategies designed to reduce their child's screen time. Families were given Time Machine TV monitoring devices to assist with allocating screen time, activity packages to promote alternative activities, online support via a website, and monthly newsletters. Control participants were given the intervention material on completion of follow-up. The primary outcome was change in children's BMI z-score from baseline to 24 weeks., Results: Children (n = 251) aged 9-12 years and their primary caregiver were randomized to receive the SWITCH intervention (n = 127) or no intervention (controls; n = 124). There was no significant difference in change of zBMI between the intervention and control groups, although a favorable trend was observed (-0.016; 95% CI: -0.084, 0.051; p = 0.64). There were also no significant differences on secondary outcomes, except for a trend towards increased children's moderate intensity physical activity in the intervention group (24.3 min/d; 95% CI: -0.94, 49.51; p = 0.06)., Conclusions: A home-based, family-delivered intervention to reduce all leisure-time screen use had no significant effect on screen-time or on BMI at 24 weeks in overweight and obese children aged 9-12 years., Trial Registration: Australian New Zealand Clinical Trials RegistryWebsite: http://www.anzctr.org.au, Trial Registration Number: ACTRN12611000164998.

Unlabelled: Cardiac rehabilitation (CR) is crucial in the management of cardiovascular disease (CVD), yet attendance is poor. Mobile technology (mHealth) offers a potential solution to increase reach of CR. This paper presents two development studies to determine mobile phone usage in adults with CVD and to evaluate the acceptability of an mHealth healthy eating CR program., Methods: CR attendees were surveyed to determine mobile phone usage rates. A second single-subject pilot study investigated perceptions of a 4-week theory-based healthy eating mHealth program and explored pre-post changes in self-efficacy., Results: 74 adults with CVD completed the survey (50/74 male; mean age 63 ± 10). Nearly all had mobile phones (70/74; 95%) and used the Internet (69/74; 93%), and most were interested in receiving CR by text message (57/74; 77%). 20 participants took part in the healthy eating pilot study. Participants read all/most of the text messages, and most (19/20) thought using mobile technology was a good way to deliver the program. The website was not widely used as visiting the website was reported to be time consuming. Exploratory t-tests revealed an increase in heart healthy eating self-efficacy post program, in particular the environmental self-efficacy subset (Mean = 0.62, SD = 0.74, p = 0.001)., Conclusions: Text messaging was seen as a simple and acceptable way to deliver nutrition information and behavior change strategies; however, future research is needed to determine the effectiveness of such programs.

Background/objectives: The most recent New Zealand Adult Nutrition Survey 2008/09 (ANS 08/9) revealed a decrease in reported energy intakes (EIs) compared with the previous 1997 National Nutrition Survey (NNS97). Conversely, measured body weights increased over the same period. We conducted an analysis on the ANS 08/9 data sets to evaluate reported EIs., Subjects/methods: Analysis was conducted on data from 3919 (1715 men and 2204 women aged > or = 15 years) survey participants who completed the 24-h dietary recall in the ANS 08/9. Under-reporting was assessed using the ratio of reported EI to estimated resting metabolic rate (EI:RMRest), and a cutoff limit of <0.9 (EI:RMRest) was used to identify low energy reporters (LERs). Results were examined by gender, body size, age and ethnicity., Results: The mean EI:RMRest (s.e.m.) was 1.34 (0.02) for men, and 1.23 (0.02) for women. Overall, 21% of men and 25% of women were classified as LERs. There was a greater prevalence of LERs among people with overweight (25%), or obesity (30%) than people with normal body weight (16%, P<0.001). The oldest age group (> or =65 years) had a greater prevalence of LERs (33%) compared with all other age groups (19-24%, P<0.001). Pacific people had a greater prevalence of LERs (33%) compared with Maori (26%, P=0.007) and European (23%, P<0.001). Compared with the NNS97, a substantial increase in the prevalence of LERs was evident in most subgroups., Conclusions: Under-reporting of EI will continue to be a major limitation of nutrition surveys without technological innovation. Care should be taken when interpreting EI data.

Food labelling on food packaging has the potential to have both positive and negative effects on diets. Monitoring different aspects of food labelling would help to identify priority policy options to help people make healthier food choices. A taxonomy of the elements of health-related food labelling is proposed. A systematic review of studies that assessed the nature and extent of health-related food labelling has been conducted to identify approaches to monitoring food labelling. A step-wise approach has been developed for independently assessing the nature and extent of health-related food labelling in different countries and over time. Procedures for sampling the food supply, and collecting and analysing data are proposed, as well as quantifiable measurement indicators and benchmarks for health-related food labelling., (© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity.)

Food prices and food affordability are important determinants of food choices, obesity and non-communicable diseases. As governments around the world consider policies to promote the consumption of healthier foods, data on the relative price and affordability of foods, with a particular focus on the difference between 'less healthy' and 'healthy' foods and diets, are urgently needed. This paper briefly reviews past and current approaches to monitoring food prices, and identifies key issues affecting the development of practical tools and methods for food price data collection, analysis and reporting. A step-wise monitoring framework, including measurement indicators, is proposed. 'Minimal' data collection will assess the differential price of 'healthy' and 'less healthy' foods; 'expanded' monitoring will assess the differential price of 'healthy' and 'less healthy' diets; and the 'optimal' approach will also monitor food affordability, by taking into account household income. The monitoring of the price and affordability of 'healthy' and 'less healthy' foods and diets globally will provide robust data and benchmarks to inform economic and fiscal policy responses. Given the range of methodological, cultural and logistical challenges in this area, it is imperative that all aspects of the proposed monitoring framework are tested rigorously before implementation., (© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity.)

We evaluated the effects of an active videogame (AVG) intervention (Sony [Tokyo, Japan] PlayStation(®) EyeToy(®)) compared with non-AVGs on body composition, physical activity, sedentary behavior, and snack food consumption among overweight 10-12-year-old children over 24 weeks. Our research showed a treatment effect on body mass index and percentage body fat in favor of the intervention group. There was no difference between groups for total physical activity levels, but there was an increase in self-reported AVG play and reductions in non-AVG play and snack food consumption in the intervention group. Research is needed to determine how to augment the effects observed in this study.

Background: Free school breakfast programmes (SBPs) exist in a number of high-income countries, but their effects on educational outcomes have rarely been evaluated in randomised controlled trials., Methods: A 1-year stepped-wedge, cluster randomised controlled trial was undertaken in 14 New Zealand schools in low socioeconomic resource areas. Participants were 424 children, mean age 9±2 years, 53% female. The intervention was a free daily SBP. The primary outcome was children's school attendance. Secondary outcomes were academic achievement, self-reported grades, sense of belonging at school, behaviour, short-term hunger, breakfast habits and food security., Results: There was no statistically significant effect of the breakfast programme on children's school attendance. The odds of children achieving an attendance rate <95% was 0.76 (95% CI 0.56 to 1.02) during the intervention phase and 0.93 (95% CI 0.67 to 1.31) during the control phase, giving an OR of 0.81 (95% CI 0.59 to 1.11), p=0.19. There was a significant decrease in children's self-reported short-term hunger during the intervention phase compared with the control phase, demonstrated by an increase of 8.6 units on the Freddy satiety scale (95% CI 3.4 to 13.7, p=0.001). There were no effects of the intervention on any other outcome., Conclusions: A free SBP did not have a significant effect on children's school attendance or academic achievement but had significant positive effects on children's short-term satiety ratings. More frequent programme attendance may be required to influence school attendance and academic achievement., Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR)-ACTRN12609000854235.

Background: Increased understanding of why and how physical activity impacts on health outcomes is needed to increase the effectiveness of physical activity interventions. A recent randomized controlled trial of an active video game (PlayStation EyeToy™) intervention showed a statistically significant treatment effect on the primary outcome, change from baseline in body mass index (BMI), which favored the intervention group at 24 weeks. In this short paper we evaluate the mediating effects of the secondary outcomes., Objective: To identify mediators of the effect of an active video games intervention on body composition., Methods: Data from a two-arm parallel randomized controlled trial of an active video game intervention (n = 322) were analyzed. The primary outcome was change from baseline in BMI. A priori secondary outcomes were considered as potential mediators of the intervention on BMI, including aerobic fitness (VO2Max), time spent in moderate-to-vigorous physical activity (MVPA), and food snacking at 24 weeks., Results: Only aerobic fitness at 24 weeks met the conditions for mediation, and was a significant mediator of BMI., Conclusion: Playing active video games can have a positive effect on body composition in overweight or obese children and this effect is most likely mediated through improved aerobic fitness. Future trials should examine other potential mediators related to this type of intervention., Trial Registration: Australian New Zealand Clinical Trials Registry Website: http://www.anzctr.org.au. Study ID number: ACTRN12607000632493.

Background: The surge in the incidence of obesity and being overweight demands new options to extend the reach of weight-loss interventions. Mobile phones provide a medium for reaching large numbers of people in a cost-effective manner. The present study aimed to explore the potential for weight-loss interventions to be delivered via mobile phone., Methods: A mixed methods approach was employed. A telephone survey was conducted with 306 randomly selected participants, and 10 focus groups were undertaken with 54 purposively selected participants. The telephone survey comprised questions exploring the nature and acceptability of any potential weight-loss programme that might be delivered via mobile phones. The focus groups were conducted to explore issues of acceptability in more depth than was possible in the survey., Results: Two-thirds of participants reported support for a mobile phone weight-loss intervention, with greater levels of support amongst younger age groups and rural Māori (the indigenous population in New Zealand). Participants liked the idea of ready access to weight-loss information, and associated feedback and encouragement. The results suggest that interventions would need to include aspects of social support, use tailored and personalised content, and be practical and relevant so that they appeal to consumers. Appropriate methods of providing social support using a mobile phone require further exploration., Conclusions: Mobile phones may provide a novel but acceptable way to deliver a weight-loss intervention. They have the potential to be automatically personalised and tailored to the needs of the individual, at the same time as being delivered at a population level., (© 2011 The Authors. Journal of Human Nutrition and Dietetics © 2011 The British Dietetic Association Ltd.)

Background: In the context of rising food prices, there is a need for evidence on the most effective approaches for promoting healthy eating. Individually-targeted behavioural interventions for increasing food-related skills show promise, but are unlikely to be effective in the absence of structural supports. Fiscal policies have been advocated as a means of promoting healthy eating and reducing obesity and nutrition-related disease, but there is little empirical evidence of their effectiveness. This paper describes the Supermarket Healthy Eating for LiFe (SHELf) study, a randomised controlled trial to investigate effectiveness and cost-effectiveness of a tailored skill-building intervention and a price reduction intervention, separately and in combination, against a control condition for promoting purchase and consumption of healthy foods and beverages in women from high and low socioeconomic groups., Methods/design: SHELf comprises a randomised controlled trial design, with participants randomised to receive either (1) a skill-building intervention; (2) price reductions on fruits, vegetables and low-joule soft drink beverages and water; (3) a combination of skill-building and price reductions; or (4) a control condition. Five hundred women from high and low socioeconomic areas will be recruited through a store loyalty card program and local media. Randomisation will occur on receipt of informed consent and baseline questionnaire. An economic evaluation from a societal perspective using a cost-consequences approach will compare the costs and outcomes between intervention and control groups., Discussion: This study will build on a pivotal partnership with a major national supermarket chain and the Heart Foundation to investigate the effectiveness of intervention strategies aimed at increasing women's purchasing and consumption of fruits and vegetables and decreased purchasing and consumption of sugar-sweetened beverages. It will be among the first internationally to examine the effects of two promising approaches - skill-building and price reductions - on diet amongst women., Trial Registration: Current Controlled Trials ISRCTN39432901.

Objective: To define the effectiveness of recent efforts by the Australian Division of World Action on Salt and Health, and the Heart Foundation in New Zealand to reduce sodium levels in breads in Australia and New Zealand., Design and Setting: Data on the sodium contents of packaged sliced bread products sold in Australian and New Zealand supermarkets were collected from the product labels of 157 breads in 2007 and 167 breads in 2010, and were compared overall, by bread type, by manufacturer, and between nations., Main Outcome Measures: Mean sodium values in bread and proportions of breads meeting the targets of 400 mg/100 g in Australia and 450 mg/100 g in New Zealand., Results: Overall mean sodium content in bread in Australia was 434 mg/100 g in 2007 and 435 mg/100 g in 2010; corresponding values for New Zealand were 469 mg/100 g and 439 mg/100 g. The proportion of Australian breads meeting the national target increased from 29% in 2007 to 50% in 2010; the proportion of New Zealand breads meeting the national target increased from 49% in 2007 to 90% in 2010. There were clear differences between the results achieved by different companies., Conclusions: Voluntary efforts by non-governmental organisations have had some impact on sodium levels in bread, particularly in New Zealand. However, substantial room for further improvement remains. If additional reductions are not achieved under the current voluntary arrangements, legislated approaches may be required.

Background: Approximately one third of New Zealand children and young people are overweight or obese. A similar proportion (33%) do not meet recommendations for physical activity, and 70% do not meet recommendations for screen time. Increased time being sedentary is positively associated with being overweight. There are few family-based interventions aimed at reducing sedentary behavior in children. The aim of this trial is to determine the effects of a 24 week home-based, family oriented intervention to reduce sedentary screen time on children's body composition, sedentary behavior, physical activity, and diet., Methods/design: The study design is a pragmatic two-arm parallel randomized controlled trial. Two hundred and seventy overweight children aged 9-12 years and primary caregivers are being recruited. Participants are randomized to intervention (family-based screen time intervention) or control (no change). At the end of the study, the control group is offered the intervention content. Data collection is undertaken at baseline and 24 weeks. The primary trial outcome is child body mass index (BMI) and standardized body mass index (zBMI). Secondary outcomes are change from baseline to 24 weeks in child percentage body fat; waist circumference; self-reported average daily time spent in physical and sedentary activities; dietary intake; and enjoyment of physical activity and sedentary behavior. Secondary outcomes for the primary caregiver include change in BMI and self-reported physical activity., Discussion: This study provides an excellent example of a theory-based, pragmatic, community-based trial targeting sedentary behavior in overweight children. The study has been specifically designed to allow for estimation of the consistency of effects on body composition for Māori (indigenous), Pacific and non-Māori/non-Pacific ethnic groups. If effective, this intervention is imminently scalable and could be integrated within existing weight management programs., Trial Registration: ACTRN12611000164998.

This study aimed to describe the location and intensity of free-living physical activity in New Zealand adolescents during weekdays and weekend days using Global Positioning Systems (GPS), accelerometry, and Geographical Information Systems (GIS). Participants (n = 79) aged 12-17 years (M = 14.5, SD 1.6) recruited from two large metropolitan high schools each wore a GPS watch and an accelerometer for four consecutive days. GPS and accelerometer data were integrated with GIS software to map the main locations of each participant's episodes of moderate-vigorous physical activity. On average participants performed 74 (SD 36) minutes of moderate and 7.5 (SD 8) minutes of vigorous activity per day, which on weekdays was most likely to occur within a 1 km radius of their school or 150 meters of their home environment. On weekends physical activity patterns were more disparate and took place outside of the home environment. Example maps were generated to display the location of moderate to vigorous activity for weekdays and weekends.