Current clinical guidelines for people at risk of heart disease in Australia recommend nutrition intervention in conjunction with pharmacotherapy(1). However, Australians living in rural and remote regions have less access to medical nutritional therapy (MNT) provided by Accredited Practising Dietitians (APDs) than their urban counterparts(2). The aim of the HealthyRHearts study was to trial the delivery of MNT by APDs using telehealth to eligible patients of General Practitioners (GPs) located in small to large rural towns in the Hunter New England region(3) of New South Wales, Australia. The study design was a 12-month pragmatic randomised controlled trial. The key outcome was reduced total cholesterol. The study was place-based, meaning many of the research team and APDs were based rurally, to ensure the context of the GPs and patients was already known. Eligible participants were those assessed as moderate-to-high risk of CVD by their GP. People in the intervention group received five MNT consults (totalling two hours) delivered via telehealth by APDs, and also answered a personalised nutrition questionnaire to guide their priorities and to support personalised dietary behaviour change during the counselling. Both intervention and control groups received usual care from their GP and were provided access to the Australian Eating Survey (Heart version), a 242-item online food frequency questionnaire with technology-supported personalised nutrition reports that evaluated intake relative to heart healthy eating principles. Of the 192 people who consented to participate, 132 were eligible due to their moderate-to-high risk. Pre-post participant medication use with a registered indication(4) for hypercholesterolemia, hypertension and glycemic control were documented according to class and strength (defined daily dose: DDD)(5). Nine GP practices (with 91 participants recruited) were randomised to the intervention group and seven practices (41 participants) were randomised to control. Intervention participants attended 4.3 ± 1.4 out of 5 dietetic consultations offered. Of the132 people with baseline clinical chemistry, 103 also provided a 12-month sample. Mean total cholesterol at baseline was 4.97 ± 1.13 mmol/L for both groups, with 12-m reduction of 0.26 ± 0.77 for intervention and 0.28 ± 0.79 for control (p = 0.90, unadjusted value). Median (IQR) number of medications for the intervention group was 2 (1–3) at both baseline and 12 months (p = 0.78) with 2 (1–3) and 3 (2–3) for the control group respectively. Combined DDD of all medications was 2.1 (0.5–3.8) and 2.5 (0.75–4.4) at baseline and 12 months (p = 0.77) for the intervention group and 2.7 (1.5–4.0) and 3.0 (2.0–4.5) for the control group (p = 0.30). Results suggest that medications were a significant contributor to the management of total cholesterol. Further analysis is required to evaluate changes in total cholesterol attributable to medication prescription relative to the MNT counselling received by the intervention group.

Cardiometabolic pregnancy complications (gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), intrauterine growth restriction (IUGR), preterm birth (PTB)) present a unique sex-specific risk factor for future cardiometabolic disease(1–5). Lifestyle modifications and healthful behaviour change (diet and physical activity), which can be supported by the delivery of evidence-based lifestyle interventions, are important factors in modifying risks of cardiometabolic conditions(2,6,7). Pregnancy and postpartum present unique windows of opportunity to intervene and prevent or delay the onset of cardiometabolic pregnancy complications and future cardiometabolic disease(2,8). Co-design considers the end-users wants, needs, preferences, characteristics and abilities throughout the entirety of the design process(9,10). Co-design processes engage women with lived experience alongside other key stakeholders including; community organisations, healthcare professionals, primary healthcare and health promotion experts14. In line with patient-centred care it offers the opportunity to design lifestyle interventions that are adapted to suit end-users, in the hope of increasing uptake, engagement, implementation success and sustainability(11). This study aims to co-design and explore stakeholders’ perspectives of the acceptability and feasibility of a lifestyle and screening intervention to reduce cardiometabolic risk amongst women at risk of or diagnosed with a cardiometabolic pregnancy complication. A descriptive qualitative research design was utilised. Two 2-hour co-design group workshops and a series of one-on-one semi-structured interviews were conducted with women with prior GDM, HDP, IUGR and/or PTB (n = 11), and research partners (obstetricians, endocrinologists, community health representatives, researchers, midwives, general practitioners, dietitians) (n = 14). Participants were provided with an overview of a potential lifestyle intervention, discussed the acceptability of each intervention component (outlined by the TIDieR framework; brief name, why, what, who provided, how, where, when and how much, tailoring, modifications, how well(12)), and the feasibility of implementation (outlined by the Theoretical Framework of Acceptability(13) and the APEASE criteria for intervention design(14)). Workshops and interviews were audio recorded, transcribed and analysed using template analysis. Analysis highlighted 10 key themes. Participants recommended the intervention is holistic, user-friendly, empowering, empathetic, patient-centred and culturally sensitive. Participants highlighted the importance of good risk communication, focusing on a positive, healthy pregnancy as opposed to risk reduction. Participants recommended providing additional resources and access to health services to complement intervention content. Participants suggested the intervention be delivered by female healthcare professionals from a range of cultural backgrounds with expertise in cardiometabolic pregnancy complications and postpartum management. Participants discussed the importance and value of the proposed intervention in filling what was perceived as a current healthcare gap for women at risk and diagnosed with cardiometabolic conditions during and following pregnancy. Engaging stakeholders to co-design an intervention that aligns with women’s and the healthcare system’s preferences, needs and priorities will support the development of an acceptable intervention for implementation in a real-world setting.

In Australia, Sports foods are increasingly being consumed by non-athletes, despite their intended purpose to supplement additional nutrient intake for high energy output by athletes(1,2). Recent evidence suggests that sports food are perceived as regular foods and are being used by non-athletes for purposes contrary to which they were designed(1,3). However, in contrast to lay-perceptions, this growing trend poses health risks, including nutrient overconsumption and unwanted health-related side effects such as caffeine overdose(4,5). Many consumers are also relying on the recommendation of sports food products through digital media sources and the use of misleading packaging information to choose products(1,6), although the factors influencing the use of these is unclear. Consumer sports food choice is complex, influenced by multiple social and ecological factors, therefore this study used an adapted Social-Ecological Model of sports food choice to examine the relevant factors that influence the perception of risks, regulations and on-pack attributes. The aim of this study was to explore non-athlete Australian sports food consumers’ perceptions of the risks associated with consumption, views about on-pack warnings and regulations in Australia and perceptions of packaging attributes displayed on these foods through a social ecological lens. This study also examined the suggestions to improve on-pack warnings and regulations of sports food products in Australia. Qualitative semi-structured online interviews were conducted with n = 15 non-athlete Australian adult sports food consumers. Reflexive thematic analysis was used to code responses using NVivo software. Participants had conflicting views on the risks associated with sports food consumption perceiving them to be high risk to others but of limited risk to themselves. Consumers trusted some packaging information more than others. That is, the Nutrition Information Panel and claims were seen as more credible than packaging colours and images. Digital media was the key source of recommendation for the selection of sports food products, particularly YouTube and podcasts. All participants in the study mentioned that warnings and regulations were too generic, not applicable to them and that government regulations lacked credibility and validity. Participants also suggested improvements for warning labels and regulatory measures such as providing more information, greater restriction on sale locations and on the ability for certain consumers to purchase these products. Consumption of sports foods by non-athletes is influenced by attitudes towards personal risks, the persuasive influence of digital media, and perceptions of the warnings and regulations as being inadequate. Findings highlight the need for stricter packaging and regulations that ensure marketing controls and provide safer sports food products for non-athletes to consume. Future research should track these perceptions over time to ensure that improvements to packaging clarity and regulatory measures impact consumer consumption of sports foods.

Traditional foods are increasingly being incorporated into modern diets. This is largely driven by consumers seeking alternative food sources that have superior nutritional and functional properties. Within Australia, Aboriginal and Torres Strait Islander peoples are looking to develop their traditional foods for commercial markets. However, supporting evidence to suggest these foods are safe for consumption within the wider general population is limited. At the 2022 NSA conference a keynote presentation titled ‘Decolonising food regulatory frameworks to facilitate First Peoples food sovereignty’ was presented. This presentation was followed by a manuscript titled ‘Decolonising food regulatory frameworks: Importance of recognising traditional culture when assessing dietary safety of traditional foods’, which was published in the conference proceedings journal(1). These pieces examined the current regulatory frameworks that are used to assess traditional foods and proposed a way forward that would allow Traditional Custodians to successfully develop their foods for modern markets. Building upon the previously highlighted works, this presentation will showcase best practice Indigenous engagement and collaboration principles in the development of traditionally used food products. To achieve this, we collaborated with a collective of Gamilaraay peoples who are looking to reignite their traditional grain practices and develop grain-based food products. To meet the current food safety regulatory requirements, we needed to understand how this grain would fit into modern diets, which included understanding the history of use, elucidating the nutritional and functional properties that can be attributed to the grain, and developing a safety dossier(2) so that the Traditional Custodians can confidently take their product to market. To aid the Traditional Custodians in performing their due diligence, we have systemically analysed the dietary safety of the selected native grain and compared it side-by-side with commonly consumed wheat in a range of in vitro bioassays and chemical analyses. From a food safety perspective, we show that the native grain is equivalent to commonly consumed wheat. The native grain has been shown to be no more toxic than wheat within our biological screening systems. Chemical analysis showed that the level of contaminants are below tolerable limits, and we were not able to identify any chemical classes of concern. Our initial findings support the history of safe use and suggest that the tested native grain species would be no less safe than commonly consumed wheat. This risk assessment and previously published nutritional study(3) provides an overall indication that the grain is nutritionally superior and viable for commercial development. The learnings from this project can direct the future risk assessment of traditional foods and therefore facilitate the safe market access of a broader range of traditionally used foods. Importantly, the methods presented are culturally safe and financially viable for the small businesses hoping to enter the market.

Urinary tract infections (UTI) are amongst the most common bacterial infections worldwide, posing significant clinical and economic burden(1). Women are more susceptible, with nearly 50–60% of women experiencing at least one UTI during their lifetime, and 30–40% experiencing recurrent UTI (rUTI) in their lifetime(1). Cystitis, the most common UTI, remains one of the most common indications for prescribing antimicrobial treatment. However, continued use is associated with antimicrobial resistance(2), a major concern to health care and economic burden. Establishing alternative safe and effective non-antibiotic therapies for prevention of rUTI in otherwise healthy women is therefore important. Cranberry-containing products have been shown to reduce risk of UTIs(3) through inducing anti-adhesive activity against uropathogenic Escherichia coli to uroepithelial cells(4). Most clinical trials to date have tested fractions from cranberry fruit, such as juice concentrate or isolated proanthocyanidins(3). This study investigated the effect of a whole cranberry fruit powder supplement on incidence of culture-confirmed UTI (primary outcome) in women with rUTI history. A multicentre, 6-month, randomised, placebo-controlled, double-blind study enrolled 150 healthy females (18–65 years, body mass index (BMI) > 17.5-<35 kg/m2) with rUTI. rUTI was defined as ≥ 3 UTIs in the last year or at least 2 UTIs in the last 6 months, confirmed by a health professional. Women with a history of > 5 UTIs in the last 6 months were excluded. Eligible participants were randomised to 1 capsule of either 500 mg/day whole cranberry powder (Swisse High Strength Cranberry [Pacran®]) or placebo. Culture-confirmed UTIs (> 108 cfu/L) from mid-stream urine samples were assessed throughout the intervention period whenever participants experienced UTI symptoms (including dysuria, urinary frequency or urgency, fever, suprapubic pain, or macroscopic haematuria), and at baseline, 3- and 6-month clinic visits. Whole cranberry powder reduced culture-confirmed UTI risk compared to placebo by 52% (adjusted relative risk [RR] = 0.48, 95% CI = [0.26, 0.87], p = 0.01); reduced Escherichia coli UTIs (RR = 0.49, 95% CI = [0.24, 1.01], p = 0.05); incidence of UTI with urinary frequency and urgency symptomatology (RR = 0.29, 95% CI = [0.13, 0.63], p < 0.01); delayed time to first UTI episode (adjusted hazard ratio [HR] = 0.36, 95% CI = [0.18, 0.74], p = 0.01); and reduced the mean total number of UTIs per participant (adjusted incidence rate ratio [IRR] = 0.41, 95% CI = [0.21, 0.79], p = 0.01). Differences between groups in incidence of symptomatic suspected UTIs, and culture-confirmed dysuria were not detected. No safety concerns were reported. In conclusion, this study provides robust evidence that whole cranberry powder is safe to consume and reduces the incidence of culture-confirmed UTI and several other UTI-related outcomes in healthy women with rUTI history.

Maternal diet during pregnancy influences the short- and long-term health of mothers and their offspring(1). Pregnant women from culturally and linguistically diverse (CALD) backgrounds potentially have challenges achieving a healthy diet due to language barriers, cultural differences and poor nutrition knowledge. Data from 2021 shows that ~7200 women who gave birth in Australia were of Chinese background(2), however, data on the dietary patterns and nutrition knowledge of pregnant women in Australia from CALD backgrounds are limited. This pilot, cross-sectional study aimed to: assess the food group, nutrient intakes and diet quality of pregnant/recently pregnant women in Australia with Chinese-speaking backgrounds, compare the intakes with national nutrition recommendations, and assess the nutrition knowledge of the women. Participants were recruited in partnership with Hunter New England Local Health District Multicultural and Refugee Health to complete an online survey, which was translated to simplified Chinese language. Eligible participants were pregnant women and women who had given birth in the previous 12-months, who were living in, but not born in Australia, who were ≥ 19 years, and primarily spoke a Chinese language. Dietary intake was assessed via the Australian Eating Survey, diet quality via the Australian Recommended Food Score (ARFS), and nutrition knowledge via a questionnaire adapted from the General Nutrition Knowledge Questionnaire. Food group serves, macronutrient, micronutrient and energy intake, and diet quality were reported as median (IQR) due to non-normal distributions. Intake of food group serves, macronutrients and micronutrients were compared with national nutrition recommendations. The mean (SD) nutrition knowledge score out of 23 was reported. Fifty participants (31.8 ± 4.3 years, mostly pregnant (66%), born in China (66%) with Mandarin as first language (62%)) reported median consumption of all five food groups below recommendations, with the poorest alignment for grain (4%) and dairy foods (4%). Median consumption of carbohydrate (46.5% EI), fat (34.5% EI) and protein (20.0% EI) met recommendations for pregnant women, but not saturated fat (12.5% EI) or dietary fibre (18.6 grams). The alignment of 16 micronutrients from food intake to recommendations was poor, particularly for iron (4%) and iodine (12%). The highest alignment to recommendations was for vitamin C (92%) and retinol (78%). The median (IQR) ARFS was 23 (18, 39) points out of 73, indicating poor overall diet quality. The mean (SD) nutrition knowledge score was 10.2 (2.9) out of 23. This sample of pregnant and recently pregnant women living in Australia with Chinese-speaking background reported suboptimal food group and nutrient intakes and overall diet quality that does not align with national nutrition recommendations. The low nutrition knowledge score suggests poor knowledge of pregnancy dietary recommendations. These findings warrant further investigation in larger samples of pregnant women from CALD backgrounds with regard to dietary intake and nutrition knowledge.

Adults living with obesity have a higher risk of eating disorders and disordered eating behaviours such as binge eating(1,2). However, the prevalence of disordered eating/eating disorders in adults presenting for obesity treatment is unknown and this information is needed to guide service provision. This systematic review aimed to estimate the prevalence of disordered eating/eating disorders in adults presenting for obesity treatment. Embase, MEDLINE and PsycINFO were searched to March 2024. Eligible studies (k) measured disordered eating/eating disorders in adults with overweight/obesity presenting for obesity treatment and included ≥ 325 participants to ensure a representative sample. Prevalence estimates were synthesised using random effect meta-analysis. 81 studies were included (n = 92,002, 75.9% female, median (IQR) age 44 (6) years, BMI 45 (11) kg/m2. Most studies were conducted in the United States (k = 44) and Italy (k = 15). Most prevalence data related to binge eating disorder or binge eating severity. The pooled prevalence of binge eating disorder, assessed by clinical interview, was 17% (95% CI: 12–22, 95% prediction interval (PI): 0–42, k = 19, n = 13447, τ2 = 0.01) using DSM-IV criteria and 12% (95% CI: 5–20, 95% PI: 0–40, k = 9, n = 7680, τ2 = 0.01) using DSM-V criteria. The pooled prevalence for severe binge eating (Binge Eating Scale score > 25) was 12% (95% CI: 8–16, 95% PI: 0–31, k = 18, n = 12136, τ2 = 0.01). For binge eating disorder, measured by clinical interview, the prevalence range for females and males was 14.9 to 27.0% (k = 12), and 4.0 to 24.1% (k = 3) respectively. For moderate to severe binge eating (Binge Eating Scale score ≥ 18) the prevalence for females and males ranged from 20.0 to 32.8%, and 7.1 to 77.5% (k = 2). Three studies reported prevalence by ethnicity. The prevalence of severe binge eating (Binge Eating Scale scores ≥ 27) was 9.5 to 41.7% in white populations (k = 2), 7.5 to 35.8% in black populations (k = 2), and 5.7% in Hispanic populations (k = 1). One study reported binge eating disorder, assessed by clinical interview, for white, black and Hispanic populations and reported prevalence of 15.3%, 11.3% and 11.4% respectively. Overall, there was high variability in the prevalence of binge eating and binge eating disorder in adults presenting for obesity treatment, with available data indicating prevalence can range up to 42%. It is important to identify which population level factors drive this heterogeneity to inform service provision however, the limited data highlights a significant knowledge gap in the reporting of eating disorders in underrepresented populations which needs to be addressed.

In recent decades there has been an increased interest in the Mediterranean diet’s (MedDiet) protective capacity against age-related diseases. The MedDiet is comprised of wholefoods, with moderate to high dietary fat and a kilojoule intake of approximately 9,300kJ(1). The Mediterranean Diet Adherence Screener (MEDAS) has allowed for rapid assessment of MedDiet adherence across intervention and cohort studies globally(2). However, well-established reductions in older adults’ energy requirements often present a barrier to full MedDiet adherence(3,4). We sought to create an energy-adjusted MEDAS (E-MEDAS) for use in populations with reduced energy requirements, with a secondary analysis to determine that the strength of the relationship between E-MEDAS adherence and cardiometabolic biomarkers is not diminished through energy-adjustment. Baseline data from independently living, 60–90 year old participants enrolled in the MedWalk clinical trial were used. Estimated energy requirements (EER) were calculated for all participants (n = 161) using gender and age specific Schofield Equations, multiplied by a physical activity level (PAL) we derived from a novel method to calculate PAL’s from Actigraph and IPAQ-E data. Three distinct energy categories of E-MEDAS criteria were identified, with evenly reduced cutoff criteria across all food components. Participants with a completed MEDAS (n = 157) had their MedDiet adherence re-scored according to the reduced criteria cutoffs. Spearman’s rank correlation coefficient analyses, with 95% confidence intervals constructed by accelerated bias-corrected bootstrapping, were used to determine the strength and direction of association between both MEDAS and E-MEDAS adherence scores and 8 cardiometabolic biomarkers. The newly calculated E-MEDAS categories included Category 3 (corresponding to the original MEDAS) with a range of 9100–10500kJ (n = 30), Category 2 with a range of 7700–9100kJ (n = 81) and Category 1 with a range of 6300–7700kJ (n = 44). There was a significant (p < 0.05) weak negative correlation between the re-scored E-MEDAS and 5 cardiometabolic biomarkers; BMI (rs = −0.228, BCa 95% CI [−0.388, −0.074]), WHR (rs = −0.189, BCa 95% CI [−0.352, −0.027]), LDL (rs = −0.174, BCa 95% CI [−0.347, 0.009]), Total:HDL Ratio (rs = −0.288, BCa 95% CI [−0.429, −0.127]), Trigs (rs = −0.235, BCa 95% CI [−0.373, −0.079]. In contrast, the original MEDAS score resulted in a significant (p < 0.05) weak negative correlation in only 3 cardiometabolic biomarkers; WHR (rs = −0.167, BCa 95% CI [−0.317, −0.011]), Total:HDL Ratio (rs = −0.205, BCa 95% CI [−0.354, −0.049], and Trigs (rs = −0.217, BCa 95% CI [−0.360, −0.054]). Ultimately, we have successfully developed two categories of E-MEDAS, using a novel calculation of PALs, for use in individuals with reduced EERs. E-MEDAS scores showed a modest increase in the strength of relationship with five cardiometabolic biomarkers, indicating that reducing serves of individual components, while maintaining the overall dietary pattern does not negate the protective capacity of a MedDiet.

Shift workers in Australia constitute approximately 16% of the workforce, with nearly half working a rotating shift pattern(1). Whilst poor dietary habits of shift workers have been extensively reported, along with increased risk of metabolic health conditions such as obesity, cardiovascular disease and diabetes compared to non-shift workers(2,3,4), studies on shift working populations rarely control for individual and lifestyle factors that might influence dietary profiles. While rotating shift work schedules have been linked with higher energy intake than daytime schedules(5), little is known about the impact of different night shift schedules (e.g., fixed night vs rotating schedules) on the diets of shift workers, including differences in 24-hour energy intake and nutrient composition. This observational study investigated the dietary habits of night shift workers with overweight/obesity and compared the impact of rotating and fixed night shift schedules on dietary profiles. The hypothesis was posited, that shift workers’ diets overall would deviate from national nutrition recommendations, and those working rotating shift schedules compared with fixed night schedules would have higher energy consumption. Participants were from the Shifting Weight using Intermittent Fasting in night shift workers (SWIFt) trial, a randomised controlled weight loss trial, and provided 7-day food diaries upon enrolment. Mean energy intakes (EI) and the percentage of EI from macronutrients, fibre, saturated fat, added sugar, alcohol, and the amount of sodium were evaluated against Australian adult recommendations. Total group and subgroup analysis of fixed night vs rotating schedules’ dietary profiles were conducted, including assessment of plausible and non-plausible energy intake reporters. Hierarchical regression analysis were conducted on nutrient intakes, controlling for individual and lifestyle factors of age, gender, BMI, physical activity, shift work exposure, occupation and work schedule. Overall, night shift workers (n = 245) had diets characterised by high fat/saturated fat/sodium content and low carbohydrate/fibre intake compared to nutrition recommendations, regardless of shift schedule type. Rotating shift workers (n = 121) had a higher mean 24-hour EI than fixed night workers (n = 122) (9329 ± 2915 kJ vs 8025 ± 2383 kJ, p < 0.001), with differences remaining when only plausible EI reporters were included (n = 130) (10968 ± 2411 kJ vs 9307 ± 2070 kJ, p < 0.001). These findings highlight poor dietary choices among this population of shift workers, and higher energy intakes of rotating shift workers, which may contribute to poor metabolic health outcomes often associated with working nightshift.

Carbohydrates are an important source of energy, playing a crucial role in the growth and development of children(1). Carbohydrate intakes in adults are well studied, but the intake and key food sources of carbohydrates during early childhood are poorly understood. Assessing carbohydrate intake and identifying key food sources of carbohydrates and their subtypes will aid in dietary monitoring to identify suboptimal intake and food sources. Thus, the current study aimed to describe the intakes of total carbohydrates and their subtypes (starch and total sugar), identify their main food sources, and examine tracking among young Australian children over the first 5 years of life. Data from children who participated in follow-ups at ages 9 months (n = 393), 18 months (n = 284), 3.5 years (n = 244), and 5 years (n = 240) in the Melbourne InFANT Program(2) were used. Child dietary intake was collected using three 24-hour recalls. Descriptive statistics were used to summarise the total carbohydrate and subtype intakes and their main food sources. Tracking was examined using Pearson’s correlations of the residualised scores across different time points. From ages 9 months to 5 years, total carbohydrate intake increased from 99.7 g/d to 174 g/d. Total sugar and starch intakes (g/d) also increased throughout early childhood. The percentage of energy (%E) from total carbohydrates remained stable over time (48.4–50.5%). However, the %E from total sugar decreased from 29.4% at 9 months to 22.6% at 5 years, while the %E from starch increased from 16.7% at 9 months to 26.0% at 5 years. The primary source of total carbohydrates at 9 months was infant formula. At later ages (18 months, 3.5 years, and 5 years), the key sources of total carbohydrate intake were bread/cereals, fruits, and milk/milk products. The major sources of total sugar intake at all time points were fruits and milk/milk products. However, intakes of total sugar from discretionary foods such as cakes/cookies increased with age. The main food sources for starch intake were consistent across all ages which included breads/cereals, cakes/cookies, and pasta. Weak to moderate tracking of total carbohydrate, total sugar, and starch (g/d) was observed from as early as age 9 months to age 5 years. Given the detrimental effects of discretionary foods on health, our results reinforce the importance of reducing sugar intake from discretionary foods and promoting healthy alternatives, such as wholegrains, from early childhood. The tracking of carbohydrate intake from as early as age 9 months suggest that carbohydrate intakes were established early in life, emphasising the importance of early dietary interventions. Our findings revealed in-depth insights into carbohydrate intake trends during early childhood, which may contribute valuable evidence to inform the refinement of carbohydrate intake recommendations in young Australian children.

Systemic weight-bias may negatively influence nutrition recommendations and outcomes in the treatment of mental illness(1,2,3). However, weight loss is often considered a primary outcome in mental health care, despite the potential harm that may come from practising within a ‘weight-centric’ paradigm(4). Therefore, it is important to consider the impact of experiences of weight-based discrimination in mental health care, as well as investigate weight-neutral approaches in relation to mental and physical health and wellbeing. This study utilised a sequential explanatory study design. First, a systematic search was performed including observational studies of adult populations, with ≥ 1 mental or physical health outcome, and ≥ 1 validated measure of eating behaviour reflective of a weight-neutral approach. Outcomes were categorised into four domains (mental health, physical health, health promoting behaviours and other eating behaviours). Risk of bias was assessed using the Newcastle-Ottawa Scale. Next, a cross-sectional online survey was conducted among a community sample with self-reported diagnoses of depression or anxiety. Questions collected experiences of weight-stigma in mental health care, and validated measures such as the Depression and Anxiety Stress Scale (DASS-21), Stigmatizing Situations Inventory-Brief (SSI-B), and Weight Bias Internalization Scale (WBIS-M). Quantitative data were statistically analysed using Jamovi, while open-ended responses were thematically analysed using an inductive approach to reach consensus. In the systematic search, 8281 records were identified with 86 studies including 75 unique datasets, and 78 unique exposures including intuitive eating (n = 48), mindful eating (n = 19), and eating competence (n = 11). Eating behaviours were significantly related to lower levels of disordered eating, and depressive symptoms, and greater body image, self-compassion, diet quality, and higher fruit and vegetable intake. Among the 66 survey respondents (mean age 35.5 ± 11y), greater experienced weight bias (SSI-B) was significantly associated with greater depressive symptoms (r = 0.281, p < 0.05), and greater internalised weight-bias (WBIS-M) was significantly associated with greater depressive symptoms (r = 0.492, p < 0.001; β = 0.414, p = 0.001), anxiety symptoms (r = 0.437, p < 0.001; β = 0.390, p = 0.003), stress (r = 0.399, p < 0.01; β = 0.371, p = 0.006) and DASS-21 total score (r = 0.513, p < 0.001; β = 0.453, p < 0.001). Respondents reported experiences of weight-stigma that resulted in the mismanagement of mental health concerns, unsolicited diet and weight loss advice, and healthcare avoidance. Experiences of weight-stigma within mental health care have the potential to negatively impact mental health and nutrition-related recommendations. However, it must be considered that eating behaviours focused on health, not weight, are positively related to a range of mental and physical health outcomes. Therefore, it is vital healthcare professionals understand and assess their own biases related to weight, to reduce the impact of weight-bias on quality of care and consider weight-neutral approaches to better support mental health and wellbeing.

Cardiovascular diseases (CVDs) are the leading cause of death worldwide(1). As poor diet quality is a major contributor to CVD burden; dietary intervention is recommended as a first-line approach to CVD prevention and management(2). Personalised nutrition (PN) refers to individualised nutrition care based on genetic, phenotypic, medical, and/or behavioural and lifestyle characteristics(3). Medical nutrition therapy by dietitians shares many of these principles and can be categorised as PN(4). PN may be beneficial in improving CVD risk factors and diet, however, this has not previously been systematically reviewed. The aim of this systematic review was to evaluate the effectiveness of PN interventions on CVD risk factors and diet in adults at elevated CVD risk. A comprehensive search was conducted in March 2023 across Embase, Medline, CINAHL, PubMed, Scopus and Cochrane databases, focusing on randomised controlled trials (RCTs) published after 2000 in English. Included studies tested the effect of PN interventions on adults with elevated CVD risk factors (determined by anthropometric measures, clinical indicators, or high overall CVD risk). Risk of bias was assessed using the Academy of Nutrition and Dietetics Quality Criteria checklist. Random-effects meta-analysis were conducted to explore weighted mean differences (WMD) in change or final mean values for studies with comparable data (studies with dietary counselling interventions), for outcomes including blood pressure (BP), blood lipids, and anthropometric measurements. Sixteen articles reporting on 15 unique studies (n = 7676) met inclusion criteria and were extracted. Outcomes of participants (n = 40–564) with CVD risk factors including hyperlipidaemia (n = 5), high blood pressure (n = 3), BMI > 25kg/m2 (n = 1) or multiple factors (n = 7) were reported. Results found potential benefits of PN on systolic blood pressure (SBP) (WMD −1.91 [95% CI −3.51, −0.31] mmHg), diastolic blood pressure (DBP) (WMD −1.49 [95% CI −2.39, −0.58] mmHg), triglycerides (TG) (WMD −0.18 [95% CI −0.34, −0.03] mmol/L), and dietary intake in individuals at high CVD risk. Results were inconsistent for plasma lipid and anthropometric outcomes. Dietary counselling PN interventions showed promising results on CVD risk factors in individuals at-risk individuals. Further evidence for other personalisation methods and improvements to methodological quality and longer study durations are required in future PN interventions.

Telomere length is a biomarker of ageing(1). A shorter telomere length is associated with an increased risk of age-related diseases and mortality. Oxidative stress and inflammation are predominant mechanisms leading to telomere shortening(2). Diets and food groups high in antioxidant and anti-inflammatory properties are shown to be protective against telomere shortening(3). The nut and seed food group is rich in nutrients such as unsaturated fats, vitamins, and minerals, and contains antioxidants and anti-inflammatory phytochemicals. Evidence is emerging on the beneficial effects of nuts and seeds in the prevention and management of age-related chronic conditions. This review aims to evaluate the role of nut and seed intake on telomere length in humans using the evidence from observational and interventional studies. Four databases, including Medline, CINAHL, Embase and Web of Science, were systematically searched from inception to 12 March 2024 for observational and interventional studies assessing the intake of nut or seed or applied nut or seed interventions and measured telomere length as an outcome in adult human participants (age ≥ 18 years). The quality assessment of the included studies was performed using the Academy of Nutrition and Dietetics Evidence Analysis Library® November 2022: Quality Criteria Checklist. Nine observational and four interventional studies were included. A positive association between nut and seed intake and telomere length was reported in three of the nine observational studies. None of the interventional studies reported a significant positive effect of nuts on telomere length. Three of the observational and interventional studies were classified as high quality, and the remaining studies were of neutral quality. Meta-analysis was not warranted due to the high heterogeneity in the telomere length measurements across the studies. The findings are inconsistent across these studies, and the evidence is insufficient to establish a beneficial role of nut and seed intake on telomere length. Larger epidemiological studies and adequately powered long-term randomised controlled trials are needed to establish the positive role of nut and seed on telomere length. However, nut and seed should continue to be recommended as a part of a healthy diet, given their proven benefits against age-related conditions.

Ecological momentary assessment (EMA) may be a valid and acceptable method of assessing dietary intake in young adults(1). EMA may overcome some of the limitations associated with traditional dietary assessment methods such as high respondent burden and memory biases(2) by capturing time-sensitive data via concise dietary surveys. However, most dietary EMA studies either deliver signal-contingent EMAs at fixed intervals or rely on the user’s memory to self-initiate event-contingent EMAs whenever they ate. This may be inappropriate for young adults due to their highly variable eating patterns(1). Young adults are particularly vulnerable to weight gain due to major life transitions and, for this population, dietary information may need to be collected near real-time to improve recall accuracy(3). Therefore, the aim of this study was to examine the feasibility (response rate) and acceptability of an EMA protocol that delivered dietary surveys at times personalised to young adults’ (18–30 years) eating patterns and to compare this to the feasibility and acceptability of EMAs delivered at fixed intervals. A randomised, double-blinded crossover design with two four-day treatment arms was used. In one arm, participants received six EMAs per day at fixed intervals. In the other arm, EMAs were delivered at times tailored to participants’ usual eating schedules (ranged between two to six EMAs per day). Usual eating schedules were determined using time-stamped food and beverage images captured by participants over the four days immediately prior to treatments. EMA questions included, but were not limited to, time of consumption and type of food or beverage group consumed. Response rates were calculated as the percentage of EMAs responded to out of the EMAs delivered. At the end of each arm, participants completed an acceptability survey assessing their opinion of the number of EMAs per day, length of the EMAs, and number of recording days. Twenty-three subjects were included (13 female; mean age 26, SD 2.1 years). Mean response rates of the fixed interval and personalised schedule treatments were 65.1% (SE 3.7%) and 66.3% (SE 3.7%), respectively. Compared to the fixed interval treatment, EMAs delivered during the personalised schedule treatment did not align closer with participants’ eating times; the average time difference between EMA delivery and reported eating time was 1.7 hours for both treatments. Participants from both treatments reported receiving too many EMAs per day but found the length of the EMA and number of days of recording to be ‘just right’. In conclusion, EMAs delivered on a personalised schedule may not improve participant adherence. Due to the irregular nature of young adults’ eating patterns, timing of EMA delivery is difficult to tailor. Future definitive trials should use more sophisticated methods of personalisation such as wearable sensors to trigger event-contingent EMAs.

Adolescents with obesity may engage in dieting to facilitate weight loss(1). However, dieting is also associated with eating disorder risk and body dissatisfaction. This study aimed to understand adolescent dieting behaviours and associations with eating disorder risk, weight bias internalisation and body appreciation. Adolescents (n = 141), median (IQR) age of 14.8 (12.9 to 17.9) years, mean (SD) BMI 35.39 (4.17) kg/m2, with obesity and ≥ 1 related complication were enrolled into the Fast Track to Health trial(2), which aimed to compare two dietary intervention. At the first dietetic visit, adolescents were asked whether they had previously seen a dietitian (yes or no) and if they had previously tried any diets; the types of diets tried were categorised. Self-report questionnaires including Eating Disorder Examination Questionnaire, Binge Eating Scale, Weight Bias Internalization Scale and Body Appreciation Scale were assessed. One-way ANOVA was used to investigate the difference in questionnaire scores based on the number of diets trialled (no diets, one diet, two/three diets). Of 141 adolescents enrolled, 68 (48.2%) had previously seen a dietitian and 106 (75.2%) had tried at least one diet. Most adolescents had tried one type of diet (n = 74, 52.5%), with 29 (20.6%) having tried two or three different diets. There were no associations between sex or age and history of seeing a dietitian or attempting to diet. Adolescent with a higher BMI, expressed as a percentage of the 95th percentile, were more likely to have seen a dietitian, but there was no association between BMI and the number of diets used. Adolescents who had tried two/three diets had higher scores on the Eating Disorder Examination Questionnaire compared to those who reported not dieting (mean [SD] 2.81 [1.12] vs 1.98 [1.08], p = 0.016). There were no differences in scores on the binge eating scale, weight bias internalization scale and body appreciation scale based on the number of diets trialled (p > 0.05). Many adolescents presenting to obesity treatment will have tried one or more diets with or without the support of a dietitian. Repeated dieting attempts may be an early indicator of eating disorder risk in this population. However, further research is needed to understand the duration of dieting and specific dieting practices used. Clinicians providing nutrition education and prescribing diet interventions should be aware of this and the potential influence on adolescent perceptions of healthy and unhealthy dieting practices.

Food is a key lever for human and planetary health(1). Shifting to more plant-based foods supports environmentally sustainable, healthy and affordable diets(1). Taste preferences are formed in early childhood(2), presenting an opportunity for influencing plant-based food intake throughout the lifespan. Early Childhood Education and Care (ECEC) are important food environments due to high attendance rates for long hours(3), where children receive half of their daily nutritional needs(4). This study aimed to understand plant-based vs animal-based protein food provision in ECEC, their contribution to key nutrients, and their costs. Two weeks’ menus and recipes were collected from Victorian ECEC between 2018 and 2019 and entered into Foodworks10 for nutritional analysis. Desktop analysis categorised meals (lunches and snacks) by protein type as animal-based (red meat, white meat, fish, eggs, dairy, processed meat), plant-based (legumes, protein-enriched plant milk, seeds), or combined (both). Recipe items were priced at a metropolitan supermarket in March 2024 to determine cost per child per day and cost per child per lunch meal. A restricted maximum-likelihood mixed-effects model was used to estimate mean differences in lunch meal costs between the different meal protein types, adjusted for serving size. Iron bioavailability was assessed using previously published algorithms. Total daily energy, protein, calcium and iron were compared to 50% of the Australian Recommended Daily Intake for 2–3 year olds(5). Eighteen centres provided menus (n = 180 days, 540 meals). Preliminary findings indicated that 73% of meals contained animal-based protein, 7% a combination of animal and plant, and 4% plant-based protein. Animal-based protein meals most often contained dairy foods (64%, n = 253), followed by red meat (13%, n = 53). Plant-based protein meals mostly contained legumes (85%, n = 17). Mean (± SD) iron provision was below recommendations (2.86 mg ± 1.47 mg). Total protein (26 g ± 12 g) and calcium provision (271 mg ± 137.21 mg) were above recommendations. Mean food cost per child per day was AUD 2.46 (± AUD 1.09) and mean lunch meal cost per child was AUD 1.36 (± AUD 0.84). Animal-based lunches were AUD 0.45 more expensive than plant-based (p ≤ 0.01, 95% CI: AUD 0.15–AUD 0.73). These findings highlight very low provision of plant-based proteins in ECEC menus. Low red meat and iron provision suggests that plant-based protein should not displace current red meat on menus. High dairy and more than sufficient calcium may indicate that ‘meat-free meals’ are predominantly dairy-based, providing an opportunity for plant-based proteins in these meals. Plant-based protein lunches were a third cheaper than animal-based counterparts, suggesting an affordable option. Young children attending ECEC settings are currently missing the opportunity for exposure to plant-based proteins as healthy, environmentally sustainable and affordable additions to menus.

Children attending Early Childhood Education and Care settings (ECEC) receive half of their daily nutritional needs from these services(1,2). Issues such as poor menu quality and high food waste in ECEC have been documented(3), which has implications for human and planetary health. Thus, monitoring food served and wasted in ECEC is crucial. Weighed measures are most rigorous, but reliable weighing protocols are needed to support accuracy(4). A self-administered audit tool for ECEC cooks was developed to measure the weight of food served (for nutritional analysis) and food wasted at pre-consumer (serving waste) and post-consumer (plate waste) levels. This tool was used in previous ECEC research(3) and offers a low cost, scalable option for monitoring diet quality and food waste. The aim of the present study was to assess the equivalence of the audit tool across administrators. Data was collected in June 2024 at a university food laboratory by a trained researcher (TR) and six research assistants (RAs) using the same protocol, and under conditions similar to those in ECEC settings. Menu and waste data from previous ECEC research(3) were used to simulate provision and waste of one meal and two snacks for 25 children over two days. Raw ingredients, simulated serving waste and plate waste were weighed and photographed first by the TR, followed by RAs. Weighing was conducted individually, and data entry sheets coded to ensure blinding of data among researchers. Coded data were entered into an Excel spreadsheet, with accuracy checks. The mean % difference and standard deviation of difference between TR and RAs for weights of raw ingredients, total food served, serving waste and plate waste were calculated. Equivalence testing was used to verify if the mean % (and 90% CI) were within established margins (± 10%). Results showed high reliability of the tool between users, with statistical equivalence for weight comparisons of total prepared food served, total serving waste and total plate waste (all p’s < 0.001). For raw ingredients most items (45 of 54) were statistically equivalent (all p’s < 0.05). Results were inconclusive for prepackaged items, grated apple and sweet chilli sauce (n = 5) and not equivalent for some small items (oil and garlic, n = 4). The audit tool could therefore be considered reliable for measuring total food served, serving waste, and plate waste, and provided accurate measurements for most individual raw ingredients. The tool provides a scalable, low-cost option to audit food provision and waste in ECEC settings. Its self-measurement enables research in geographically diverse ECEC settings. It also has the potential of becoming a support strategy for ECEC to monitor and improve their own food provision and waste levels. Future research could focus on digitalisation of the tool.

Low vitamin D status (circulating 25-hydroxyvitamin D [25(OH)D] concentration < 50 nmol/L) affects nearly one in four Australian adults(1). The primary source of vitamin D is sun exposure; however, a safe level of sun exposure for optimal vitamin D production has not been established. As supplement use is uneven, increasing vitamin D in food is the logical option for improving vitamin D status at a population level. The dietary supply of vitamin D is low since few foods are naturally rich in vitamin D. While there is no Australia-specific estimated average requirement (EAR) for vitamin D, the Institute of Medicine recommends an EAR of 10 μg/day for all ages. Vitamin D intake is low in Australia, with mean usual intake ranging from 1.8–3.2 μg/day across sex/age groups(2), suggesting a need for data-driven nutrition policy to improve the dietary supply of vitamin D. Food fortification has proven effective in other countries. We aimed to model four potential vitamin D fortification scenarios to determine an optimal strategy for Australia. We used food consumption data for people aged ≥ 2 years (n = 12,153) from the 2011–2012 National Nutrition and Physical Activity Survey, and analytical food composition data for vitamin D3, 25(OH)D3, vitamin D2 and 25(OH)D2(3). Certain foods are permitted for mandatory or voluntary fortification in Australia. As industry uptake of the voluntary option is low, Scenario 1 simulated addition of the maximum permitted amount of vitamin D to all foods permitted under the Australia New Zealand Food Standards Code (dairy products/plant-based alternatives, edible oil spreads, formulated beverages and permitted ready-to-eat breakfast cereals (RTEBC)). Scenarios 2–4 modelled higher concentrations than those permitted for fluid milk/alternatives (1 μg/100 mL) and edible oil spreads (20 μg/100 g) within an expanding list of food vehicles: Scenario 2—dairy products/alternatives, edible oil spreads, formulated beverages; Scenario 3—Scenario 2 plus RTEBC; Scenario 4—Scenario 3 plus bread (which is not permitted for vitamin D fortification in Australia). Usual intake was modelled for the four scenarios across sex and age groups using the National Cancer Institute Method(4). Assuming equal bioactivity of the D vitamers, the range of mean usual vitamin D intake across age groups for males for Scenarios 1 to 4, respectively, was 7.2–8.8, 6.9–8.3, 8.0–9.7 and 9.3–11.3 μg/day; the respective values for females were 5.8–7.5, 5.8–7.2, 6.4–8.3 and 7.5–9.5 μg/day. No participant exceeded the upper level of intake (80 μg/day) under any scenario. Systematic fortification of all foods permitted for vitamin D fortification could substantially improve vitamin D intake across the population. However, the optimal strategy would require permissions for bread as a food vehicle, and addition of higher than permitted concentrations of vitamin D to fluid milks/alternatives and edible oil spreads.

Most Australians consume excess sodium and inadequate potassium both causing high blood pressure—the leading risk factor for death in Australia(1). Switching regular salt to potassium-enriched, reduced-sodium salt is a novel solution, shown to lower blood pressure, cardiovascular disease risk and premature death(2). The aim of this study was to explore Australian adults’ knowledge, attitudes and behaviours related to potassium-enriched salt. Adults aged ≥ 18 years and who were the main or joint grocery buyer were recruited through a web panel provider between February and March 2024 to complete an online survey. Quotas were used to achieve representation of the age, sex and geographical distribution in Australia. The survey was developed based on existing questionnaires of consumers’ perception of potassium-enriched salt identified in a systematic review, and the behaviour change wheel framework to allow for a systematic assessment of consumers’ capability, opportunity and motivation to switch to potassium-enriched salt. Survey responses that were completed in less than one-third of the median time (< two minutes and 20 seconds) were excluded from analysis. All data were collated and analysed using the statistical program Stata/SE 14.0 (StataCorp LP). A total of 4113 adults (52% female) with a mean (SD) age of 47.9 years (18.3) completed the survey and were eligible for inclusion. About half (47%) of participants reported that they have seen/heard of a potassium-enriched salt. Of those, 41% always, often or sometimes use potassium enriched salt with the main reasons being it is what’s available at home (32%) and it was recommended by a healthcare professional (29%). However, only 3% of all participants reported that potassium-enriched salt or low-sodium salt was the main type of salt used during cooking and eating at home. Most participants reported that they could be influenced to switch to potassium-enriched salt by the following factors, if it was better for their health (85%), affordable (78%), recommended by healthcare professionals (75%) and tasted good (73%). Most participants believed that individuals (77%), food manufacturers (68%) and fast-food chains (65%) were responsible for making the switch to potassium-enriched when told it was a healthier alternative to regular salt. A greater proportion of participants correctly identified that eating more potassium was beneficial for health (73%) compared to those that correctly identified that eating more sodium was not beneficial for health (57%). While current knowledge and use of potassium-enriched salt is low in Australia, the study identified existing and potential drivers for switching to potassium-enriched salt. The study highlights greater awareness-raising activities about the health benefits and acceptable taste of potassium-enriched salt, particularly by healthcare professionals, could help scale-up the switch to potassium-enriched salt.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition affecting 1 in 7 Australians ≥ 40 years(1) and is the third leading cause of death worldwide(2). COPD exacerbations are the leading cause of preventable hospital admission in Australia(3), with viral and bacterial infections being the primary cause. The gut and lungs share a mucosal immune system known as the gut-lung axis(4). The gut contains the bodies largest community of microorganisms, known as the gut microbiota, and disruption to the gut microbiota is implicated in chronic diseases such as Inflammatory Bowel Disease, obesity and type 2 diabetes(5). Dietary intake modulates the gut microbiota via several pathways. Importantly, gut microbiota produce metabolites via digestion, and these microbial metabolites can modulate the immune system, and exert both beneficial and detrimental effects systemically. Therefore, we aimed to assess the potential of gut-derived microbial metabolites to modify immune cell responses to stimuli known to induce COPD exacerbations. Gut microbial metabolites, including seven tryptophan metabolites, and one secondary bile acid were selected by literature review. In control adults (n = 8), peripheral blood mononuclear cells (PBMC) were isolated via Lymphoprep™ density gradient centrifugation and seeded 2 × 106 cells/mL. Metabolite dose-curves (1–100 μM) were generated to determine optimal concentration. Post-3-hour metabolite incubation, PBMCs were stimulated with either lipopolysaccharide (LPS) (24 hr) or influenza-A (H1N1) (48 hr). PBMC production of anti-viral and anti-inflammatory cytokines IFN-γ, IL-6, TNF-α and IL-1β was assessed by DuoSet® ELISA. Cell viability post-metabolite incubation was confirmed via MTT assay. Cytokine dose-curves following metabolite treatment and stimulation were produced (n = 4/metabolite). Metabolite concentrations were selected based on reduction of LPS-induced TNF-α and IL-1β secretion, reduced influenza-A-induced IL-6 secretion, and increased influenza-A-induced IFN-γ secretion. Optimal metabolite concentrations included: secondary bile acid lithocholic acid (1 μM), and tryptophan metabolites nicotinamide (5 μM), indole-3-acetic acid (1 μM), kynurenic acid (5 μM), 3-hydroxyanthranilic acid (10 μM). Tryptophan metabolites cinnabarinic acid was dose-dependently pro-inflammatory, and tryptamine and 2-picolinic acid had no effect. MTT assays (n = 3/metabolite) found metabolites were not cytotoxic at the concentrations tested. These data show that gut-derived microbial metabolites modify immune cell responses to infection. These findings will inform further research which will examine the effects of microbial metabolites in immune cells from adults with COPD and assess the role of the gut microbiota in infectious COPD exacerbations.