A comprehensive overview and qualitative analysis of government-led nutrition policies in Australian institutions

Barriers and facilitators to implementation of healthy food and drink policies in public sector workplaces: a systematic literature review

CONTEXT

Many countries and institutions have adopted policies to promote healthier food and drink availability in various settings, including public sector workplaces.

OBJECTIVE

The objective of this review was to systematically synthesize evidence on barriers and facilitators to implementation of and compliance with healthy food and drink policies aimed at the general adult population in public sector workplaces.

DATA SOURCES

Nine scientific databases, 9 grey literature sources, and government websites in key English-speaking countries along with reference lists.

DATA EXTRACTION

All identified records (N = 8559) were assessed for eligibility. Studies reporting on barriers and facilitators were included irrespective of study design and methods used but were excluded if they were published before 2000 or in a non-English language.

DATA ANALYSIS

Forty-one studies were eligible for inclusion, mainly from Australia, the United States, and Canada. The most common workplace settings were healthcare facilities, sports and recreation centers, and government agencies. Interviews and surveys were the predominant methods of data collection. Methodological aspects were assessed with the Critical Appraisal Skills Program Qualitative Studies Checklist. Generally, there was poor reporting of data collection and analysis methods. Thematic synthesis identified 4 themes: (1) a ratified policy as the foundation of a successful implementation plan; (2) food providers' acceptance of implementation is rooted in positive stakeholder relationships, recognizing opportunities, and taking ownership; (3) creating customer demand for healthier options may relieve tension between policy objectives and business goals; and (4) food supply may limit the ability of food providers to implement the policy.

CONCLUSIONS

Findings suggest that although vendors encounter challenges, there are also factors that support healthy food and drink policy implementation in public sector workplaces. Understanding barriers and facilitators to successful policy implementation will significantly benefit stakeholders interested or engaging in healthy food and drink policy development and implementation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021246340.

Addressing nutritional issues and eating behaviours among university students: a narrative review

University life is a critical period for establishing healthy eating habits and attitudes. However, university students are at risk of developing poor eating habits due to various factors, including economic conditions, academic stress and lack of information about nutritional concepts. Poor diet quality leads to malnutrition or overnutrition, increasing the risk of preventable diseases. Food environments on university campuses also play a significant role in shaping the dietary habits of students, with the availability of and accessibility to healthy food options being important factors influencing food choices and overall diet quality. Disordered eating habits and body dissatisfaction are prevalent among university students and can lead to eating disorders. Income and living arrangements also influence dietary habits, with low household income and living alone being associated with unhealthy eating habits. This study is a narrative review that aimed to address nutritional issues and eating behaviours, specifically among university students. We investigated the eating behaviours of university students, including their dietary patterns, food choices and food environments. The objective of this review was to provide insights into the nutritional issues and eating behaviours of university students, with the aim of identifying target areas for intervention to improve the overall health and wellbeing among college students. University food environments need to be restructured to promote healthy eating, including the availability, accessibility, affordability and labelling of healthy foods, and policies to limit the availability of unhealthy foods and drinks on campus.

Ascorbic acid deficiency amongst spondylodiscitis patients

BACKGROUND

Spondylodiscitis can be a disabling and life-threatening infection. Ascorbic Acid is crucial for neutrophil function and collagen formation. Its association and clinical relevance in spondylodiscitis has not been previously examined.

AIMS

To determine the prevalence, characteristics, and clinical outcomes of spondylodiscitis patients with Ascorbic Acid deficiency.

METHODS

Sixty-eight consecutive patients admitted with spondylodiscitis, between December 2021 and August 2023 were included. Clinical characteristics, Ascorbic Acid levels and clinical outcomes were evaluated.

RESULTS

Thirty-seven patients had Ascorbic Acid levels taken during admission. The median initial Ascorbic Acid level was 15 μmol/L with an IQR 6.5-27 μmol/L. Depletion defined as <28 μmol/L was present in 78% of patients. Deficiency defined as ≤11 μmol/L was present in and 46% of patients. Patients with depletion were more likely to require Intensive Care Admission (absolute risk increase = 24.1%; 2.6%-45.7%). Fifteen patients had repeat serum levels taken during admission with median increase of 17 μmol/L and an IQR 0-26 μmol/L. Patients that received supplementation had a significantly greater increase in Ascorbic Acid levels compared with those that did not receive supplementation (P = 0.002).

CONCLUSION

Ascorbic acid deficiency is highly prevalent amongst spondylodiscitis patients. Depletion was associated with worse outcomes. Replacement significantly increased serum levels in comparison to standard hospital diet. The clinical significance of replacement remains to be evaluated.

Tools and resources used to support implementation of workplace healthy food and drink policies: A scoping review of grey literature

AIMS

This study aimed to identify and evaluate tools and resources used to support the implementation of workplace healthy food and drink policies, primarily in Australia and New Zealand.

METHODS

A scoping grey literature review included searches of government agencies and non-governmental organisations' websites in six English-speaking countries, public health nutrition intervention databases and Google search engine queries. Paper-based and digital tools were included if they were written in English, referred to within a policy or on a policy's website, and primarily targeting supply-side stakeholders. Tools were evaluated on two domains: 'Features' (summarised descriptively) and 'Usability and Quality' (with inter-rater reliability scores calculated using an intraclass correlation coefficient).

RESULTS

Twenty paper-based tools were identified relating to Australian (n = 14) and New Zealand (n = 6) policies, and a further six digital tools were identified from Australia (n = 3) and Canada (n = 3). Target audiences included workplace managers, food providers and suppliers. The paper-based tools focused on general implementation guidance. In contrast, digital tools tended to support specific elements of policy implementation. 'Usability and Quality' scores ranged from 2.9 to 4.5 (out of 5.0) for paper-based tools, and 3.9 to 4.2 for digital tools, with a moderate agreement between reviewer scores (intraclass correlation coefficient 0.523, p = 0.010).

CONCLUSIONS

A range of tools have been developed to support the implementation of workplace healthy food and drink policies. Understanding the strengths and limitations of current tools will assist in developing improved aids to support policy implementation.

Perspective: Challenges and Strategies to Reduce the Sodium Content of Foods by the Food Service Industry

Most Americans have dietary sodium intakes that exceed the recommended limits, which is a risk factor for hypertension and CVD. The share of total food expenditures for foods prepared and consumed away from home (FAFH) is ∼55%. These foods are consumed at various venues, including restaurants, workplaces, schools and universities, military installations, and assisted living/long-term care facilities. The food service industry has dealt with and continues to deal with various challenges in its attempt to reduce the sodium content in the foods that they prepare and sell. Despite these challenges, there have been various successful strategies used to reduce the sodium content in FAFH. This perspective article provides an overview of the challenges and strategies that have been used by the food service industry to reduce sodium in FAFH, as well as future sodium reduction strategies. Because of the widespread consumption of FAFH, implementing such future strategies could have a profound impact on the sodium content of the American diet.

A Cross-Sectional Evaluation of the Food Environment at an Australian University Campus

University food environments have a strong influence on the dietary choices of students and staff. The aim of this study was to assess the food environment at a large university in Sydney, Australia. Data were collected between March and July 2022 from 27 fixed food outlets and 24 vending machines. The healthiness of the food environment was evaluated using the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework (‘Framework’), which assesses food environment parameters including the availability, placement, and promotion of ‘Everyday’ (healthy) and ‘Occasional’ (less healthy) products. Each parameter was evaluated overall and across each food outlet type. Across all outlets, Everyday foods and drinks made up 43.9% of all products. Only two outlets met the Framework’s product availability benchmark of ≥75% Everyday foods and drinks. A total of 43 outlets (84.3%) sold sugary drinks as part of their product range. Occasional products made up 68.4%, 53.3%, and 59.9% of all items for sale at checkout areas, countertops, and eye-level shelves, respectively. Finally, 79.7% of meal deals included Occasional products. Our findings highlight the need to improve the availability, placement, and promotion of foods and drinks sold at a major university campus in Sydney, Australia.

Are mothers under lunchbox pressure? An exploration of the experiences of Victorian mothers preparing lunchboxes for their children

ISSUE ADDRESSED

A healthy diet is particularly important during childhood. Research suggests that more than 95% of Australian primary school aged children do not eat a diet consistent with the Australian Dietary Guidelines, putting them at risk of poor health. Interventions to improve the quality of children's lunchboxes may help address this issue. However, there is limited understanding of the factors impacting lunchbox preparation.

METHODS

This study explored the experiences of 10 mothers of Victorian primary school students. Mothers took part in semi-structured interviews exploring their views on lunchbox preparation and food choices. The study used a Constructivist Grounded Theory methodology and data were analysed using an inductive, thematic approach.

RESULTS

Analysis of the interviews yielded four main themes. (i) Mothers experienced a range of non-nutritional barriers that impacted the food choices they made for their children. (ii) Children's preferences influenced parental food choices. (iii) Mothers experienced and/or perceived judgement about the food choices they make for their children. And (iv) Mothers identified a lack of support and information from schools about what was appropriate for school lunch.

CONCLUSION

Findings of this study indicate that mothers are concerned with balancing nutrition and child preferences within the broader context of guidelines, perceived or real judgement and income constraints. SO WHAT?: The school environment may be an ideal setting to promote healthy eating but support for parents is needed. This is the first study in Victoria exploring mothers' perspectives on lunchbox preparation and provides initial information on which future research can build.

Review of national nutrition standards with salt-related criteria for publicly funded institutions around the world

CONTEXT

Creating healthy food environments through nutrition standards for publicly funded institutions (eg, schools, workplaces, and hospitals) provides an important opportunity to improve population diets.

OBJECTIVE

This study aimed to identify countries with national nutrition standards for publicly funded institutions that included salt-related criteria and to describe and summarize these initiatives.

DATA SOURCES

Peer-reviewed and grey literature was searched to December 2019, including MEDLINE, CENTRAL, Embase, TRoPHI, LILACS, Web of Science, Cochrane Public Health Group Specialised Register, and Effective Public Health Practice Project Database. In addition, a questionnaire was sent to country contacts and salt-reduction experts, and a targeted search on relevant government websites was conducted.

DATA EXTRACTION

Key characteristics of the national nutrition standards for publicly funded institutions were extracted, including name, governance, institution type, implementation status, and details of food and nutrient criteria.

DATA ANALYSIS

Nutrition standards were analyzed by World Health Organization region, World Bank income level, institution type, type of criteria, regulatory approach, and method of application. Sixty-six countries were identified as having national nutrition standards that included salt-related criteria for at least one publicly funded institution. Standards were more prevalent in the European Region, high-income countries, and schools compared to other regions, income levels, and institution types, respectively. Most standards were mandatory and contained nutrition criteria pertaining to both foods and nutrients.

CONCLUSION

Nutrition standards have the potential to significantly improve diets, but there is considerable scope to develop and implement nutrition standards more effectively using the new World Health Organization Action Framework.

A political economy analysis protocol: Case study implementing nutrition and sustainability policy into government food procurement

Most Australian state and territory governments have healthy food provisioning policies targeting availability of unhealthy food at the retail level, and sustainability policies promoting a life-cycle approach to procurement. However, it remains unclear if health and sustainability are important considerations in awarding contracts, and whether these high-level policies are implemented into supplier contracts. A political economy analysis framework has been developed to prospectively identify and explain barriers and enablers to policy implementation. Using food procurement in Queensland and South Australia as case studies, the political economy analysis seeks to understand the structural and contextual factors, bargaining processes, stakeholders, and incentives and ideas surrounding food procurement. It involves a desktop and content analysis of existing policies and food contracts, and key informant interviews with government and industry stakeholders. Participants will be targeted across different departments (e.g. health, environment, treasury) and in varying roles from policy design, contract management and food service, and industry suppliers in different food and drink categories (e.g. meat, packaged foods, beverages, fruit & vegetables). Participants will be recruited using purposive sampling. Thematic analysis of interview transcripts will be undertaken, informed by the political economy analysis framework. The study will identify current food procurement policy implementation barriers and enablers, including why high-level policies aren’t embedded into contracts, mechanisms for achieving policy coherence and future opportunities for addressing barriers and incorporating socio-economic, public health and environmental considerations into purchasing practices. Ultimately, the study will achieve impact by informing a whole of government approach to health and the environment by elevating the priority of health and sustainability in procurement (short term), increasing the availability of healthy and sustainable foods (medium term), and improving health and environmental outcomes (long term). To our knowledge this is the first political economy analysis of food procurement in Australia.

Creating healthy hospital retail food environments: Multiple pathways to successful at scale policy implementation in Australia

OBJECTIVE

In 2017, the Australian state of New South Wales introduced a revised policy to provide a healthy food and drink environment for staff and visitors in the state's publicly funded health facilities. We sought to understand how contextual factors, intervention features and the responses of diverse stakeholders affected the policy's implementation in public hospitals.

METHODS

Ninety-nine interviews were conducted with chief executives, implementers and retailers in the health and food retail systems after the target date for the implementation of 13 initial policy practices. Stakeholder responses were analysed to understand commitment to, engagement with and achievement of these practices and the different contexts and implementation approaches that prompted these responses.

RESULTS

Key mechanisms that drove systemic change included stakeholders' broad acceptance of the policy premise; stakeholders' sense of accountability and desire for the policy to succeed; and the policy's perceived benefits, feasibility and effectiveness. Important underpinning factors were chief executives' commitment to implementation and monitoring, a flexible approach to locally tailored implementation and historical precedents.

CONCLUSIONS

This study provides policy and practice insights for the initial phase of state-wide implementation to achieve change in health facility food retail environments.

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

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

Awareness of and Participation in School Food Programs in Youth from Six Countries

BACKGROUND

School-based meal programs can promote healthy dietary intake in youth. However, limited data exist regarding the impact of income-targeted school meal programs across countries, particularly among food-insecure youth.

OBJECTIVES

We examined self-reported awareness of and participation in free school meal programs, and associations with dietary intake in youth from 6 countries with differing national school meal policies.

METHODS

Data were collected through the 2019 International Food Policy Study Youth Survey, a cross-sectional survey of 10,565 youth aged 10-17 y from Australia, Canada, Chile, Mexico, the United Kingdom, and the United States. Regression models examined: 1) country differences in awareness of and participation in breakfast and lunch programs; and 2) associations between lunch program participation and intake of fruit and vegetables, and "less healthy" foods during the previous school lunch day.

RESULTS

Awareness of and participation in free breakfast and lunch programs varied across countries. Approximately half of USA and Chilean students participated in school lunch programs-the countries with the most comprehensive national policies-compared with one-fifth of students in the United Kingdom, and ∼5% in Australia, Canada, and Mexico (P < 0.001 for all contrasts). In the United States and Chile, more than two-thirds of youth with the highest level of food insecurity participated in lunch programs, compared with 45% in the United Kingdom, 27% in Canada, and ≤20% in Australia and Mexico. In all countries, youth reporting school lunch program participation were more likely to report fruit and vegetable intake during their previous school lunch (P < 0.001), and higher intake of "less healthy" food in all countries except the United States and Chile.

CONCLUSIONS

More comprehensive national policies were associated with greater participation in school meal programs, particularly among youth at greatest risk of food insecurity, as well as healthier dietary intake from school lunches.

Development of the University Food Environment Assessment (Uni-Food) Tool and Process to Benchmark the Healthiness, Equity, and Environmental Sustainability of University Food Environments

Globally, there is increasing interest in monitoring actions to create healthy, equitable and environmentally sustainable food environments. Currently, there is a lack of detailed tools for monitoring and benchmarking university food environments. This study aimed to develop the University Food Environment Assessment (Uni-Food) tool and process to benchmark the healthiness, equity, and environmental sustainability of food environments in tertiary education settings, and pilot test its implementation in three Australian universities in 2021. The Uni-Food tool development was informed by a review of the literature and input from an expert advisory panel. It comprises three components: (1) university systems and governance, (2) campus facilities and environments, and (3) food retail outlets. The process for implementing the tool is designed for universities to self-assess the extent to which they have implemented recommended practice in 68 indicators, across 16 domains, weighted based on their relative importance. The pilot implementation of the tool identified moderate diversity in food environments across universities and highlighted several opportunities for improvements at each institution. The assessment process was found to be reliable, with assessors rating the tool as easy to use, requiring minimal resources. Broad application of the tool has the potential to increase accountability and guide best practice in tertiary education and other complex institutional settings.

Parents' and teachers' views of the promotion of healthy eating in Australian primary schools

BACKGROUND

Primary schools have long been identified as appropriate settings for improving the healthy eating behaviours of children and helping them develop food skills. This qualitative study explored the views of Australian primary school parents and teachers about schools' strengths and weaknesses in promoting healthy eating and equipping children with food skills.

METHODS

Nineteen parents and 17 teachers from Victoria participated in semi-structured interviews. Audio recordings were transcribed and underwent thematic analysis using Nvivo.

RESULTS

This study demonstrated that parents and teachers believed that several facilitators helped promote children's healthy eating. These included food and nutrition education (FNE) programs, the community-based nature of schools, and teacher role modelling and the authority schools possess over children. Time scarcity, lack of teacher expertise, lack of leadership and funding were reported as barriers. School food environments such as canteens, lunch orders, fundraising events and school fairs were identified as both weaknesses and strengths by parents and teachers, which indicated inconsistent implementation of school nutrition policies across schools.

CONCLUSIONS

Australian primary schools demonstrate some useful efforts to promote healthy eating among children. However, there are numerous facilitators and barriers which impact on the promotion of healthy eating. These factors need to be addressed in order to develop healthy eating habits further among elementary students. These results provide directions for policymakers and school managers, as they point to the areas that need to be improved to assist the design of schools that better promote healthy eating among children.

"Just So You Know, It Has Been Hard": Food Retailers' Perspectives of Implementing a Food and Nutrition Policy in Public Healthcare Settings

Mandated policies to improve food environments in public settings are an important strategy for governments. Most Australian governments have mandated policies or voluntary standards for healthy food procurement in healthcare facilities, however, implementation and compliance are poor. A better understanding of the support required to successfully implement such policies is needed. This research explored food retailers' experiences in implementing a mandated food and nutrition policy (the Policy) in healthcare settings to identify barriers, enablers, and impacts of compliance. Three 90-min workshops facilitated by two public health practitioners were undertaken with 12 food retailers responsible for operating 44 outlets across four hospitals in Perth, Western Australia. Workshop discussions were transcribed non-verbatim and inductive thematic content was analyzed. Three main themes were identified: (1) food retailers had come to accept their role in implementing the Policy; (2) the Policy made it difficult for food retailers to operate successfully, and; (3) food retailers needed help and support to implement the Policy. Findings indicate the cost of implementation is borne by food retailers. Communications campaigns, centralized databases of classified products, reporting frameworks, recognition of achievements, and dedicated technical expertise would support achieving policy compliance. Feasibility assessments prior to policy implementation are recommended for policy success.