Polycystic Ovary Syndrome PCOS is an endocrine disorder affecting 8 to 13% of reproductive aged women(1). Dietary and physical activity changes are the first-line therapy to assist with symptom and weight management and to reduce the risk of reproductive, metabolic and psychological comorbidities(2). However, women with PCOS have a higher weight, experience weight gain, and a higher prevalence of living in a larger body. Health care professionals (HCPs) play a crucial role in delivering diet and physical activity advice for people with PCOS. Thus, the aim of this systematic review is to understand the barriers, facilitators, experiences, and perceptions of engagement and compliance with diet and physical activity modifications in people with PCOS and in HCPs providing or referring people with PCOS to diet and physical activity modifications. A mixed-method systematic review was conducted with quantitative studies narratively synthesised and all studies thematically analysed. There were 68 eligible papers, including n = 59 (n = 5198) people with PCOS and n = 17 (n = 2,622) HCPs. Several themes were identified as impacting people with PCOS’ ability to make diet and physical activity changes. HCP education on PCOS management through diet and physical activity was viewed by HCPs and people with PCOS to be inadequate, further impacting the quality of care and health outcomes. Dietary and physical activity advice delivered by a multidisciplinary team, including dietitians, was identified as a key component for change. Both people with PCOS and HCPs agreed that there was a need for individualised and PCOS-specific diet and physical activity advice. However, HCPs viewed that there was limited evidence supporting these recommendations and a lack of time to deliver this care. Weight stigma was identified as impacting both those in larger and smaller bodies with PCOS, reducing the quality of care and affecting self-perception and mental health. People with PCOS perceived that diet and physical activity are overly focused on weight loss and fertility, independent of their own personal motivations and goals. Systemic changes, including receiving diet and physical activity advice that meet the individual’s needs, are necessary for leading to long-term sustainable changes and improvements in health outcomes. A multidisciplinary team approach and an overhaul of HCPs’ perceptions and mentality of weight and weight-centric care for those with PCOS are essential in delivering effective diet and physical activity advice.

People with polycystic ovary syndrome (PCOS) have higher weight gain and psychological distress compared to those without PCOS(1). While COVID-19 restrictions led to population level adverse changes in lifestyle, weight gain and psychological distress(2), their impact on people with PCOS is unclear. The aim of this study was to investigate the impact the 2020 COVID-19 restrictions had on weight, physical activity, diet and psychological distress for Australians with PCOS. Australian reproductive-aged women participated in an online survey with assessment of weight, physical activity, diet and psychological distress. Multivariable logistic and linear regression were used to examine associations between PCOS and residential location with health outcomes. On adjusted analysis, those with PCOS gained more weight (2.9%; 95% CI; 0.027–3.020; p = 0.046), were less likely to meet physical activity recommendations (OR 0.50; 95% CI; 0.32–0.79; p = 0.003) and had higher sugar-sweetened beverage intake (OR 1.74; 95% CI 1.10–2.75; p = 0.019) but no differences in psychological distress compared to women without PCOS. People with PCOS were more adversely affected by COVID-19 restrictions, which may worsen their clinical features and disease burden. Additional health care support may be necessary to assist people with PCOS to meet dietary and physical activity recommendations.

Preconception diet is a proposed modifiable risk factor for infertility(1). However, there is no official guidance for women in the preconception period as to which dietary approaches may improve fertility. A comprehensive synthesis of the relevant evidence is key to determine the potentially effective dietary patterns and components as well as evidence gaps, and to provide information for nutritional recommendations for couples planning a pregnancy. In this systematic scoping review, four electronic databases (Medline and EMBASE via Ovid processing, CAB Direct, and CINAHL via EBSCO) were searched for observational studies (prospective and retrospective cohort, cross-sectional, and case–control studies) from inception to 27 September 2021. Eligible studies included women of reproductive age during the preconception period, and evaluated exposures related to preconception diet and outcomes related to fertility. Results were synthesised using a descriptive approach. A total of 36 studies were eligible for inclusion (31 prospective, 3 cross-sectional, and 2 case–control studies) and were published between 2007 and 2022. Of the assessed dietary exposures, increased adherence to the Mediterranean diet displayed the strongest and most consistent association with improved clinical pregnancy rates. Reducing trans fatty acids (TFAs), saturated fatty acids, and discretionary food intake (fast food and sugar-sweetened beverages) were associated with improvements in live birth, clinical pregnancy rates, and related ART outcomes. The dietary components of seafood, dairy, and soy demonstrated inconsistent findings across the few included studies. Due to heterogeneity and the limited available literature on most exposures, there is insufficient evidence to support any specific dietary approach for improving fertility. However, following some of the dietary approaches outlined in this review (anti-inflammatory diets, reducing TFA, and discretionary food intake) are consistent with broad healthy eating guidelines, have little to no associated risk, and offer a plausible set of possible benefits. This warrants further exploration in randomised controlled trials.

While there is a recognised role of optimising lifestyle behaviours such as diet and physical activity in the management of infertility, the best practice for lifestyle management of infertility remains unknown, and factors influencing the lifestyle behaviours of people with infertility are not well understood. The aim of this systematic review is to evaluate the barriers and enablers to a healthy lifestyle in people with infertility, from the perspectives of people with infertility and health professionals, in order to inform optimal behavioural change strategies for lifestyle management of infertility. Ovid MEDLINE(R), PsycINFO, EMBASE, EBM Reviews, and CINAHL Plus were searched from inception to 12th September 2022. Eligible studies were qualitative, quantitative or mixed-methods primary studies which explored barriers and/or enablers to lifestyle for infertility management, from the perspectives of people with infertility and/or health professionals. Two independent reviewers performed quality assessment, using the Centre for Evidence-Based Management Critical Appraisal of a Survey Tool (quantitative and mixed-methods studies) and the Critical Appraisal Skills Programme Qualitative Checklist (qualitative and mixed-methods studies). Data were analysed by inductive thematic analysis with themes mapped to the Capability, Opportunity, Motivation and Behaviour (COM-B) model(1) and Theoretical Domains Framework (TDF)(2). Relevant behaviour change techniques (BCTs)(3) to target the identified enablers and barriers were suggested. After screening 10703 citations and 82 full-texts, 22 studies were included (12 quantitative, 7 mixed-methods and 3 qualitative) with 18 studies including women with infertility (n = 2442), 10 including men with infertility (n = 1372) and 6 including health professionals (n = 261). From the perspectives of people with infertility, themes related to capability (e.g. strategies for behaviour change), opportunity (e.g. limited time, resources and money) and motivation (e.g. interplay between lifestyle and emotional state); themes mapped to 8 TDF domains. From the perspectives of health professionals, themes related to capability (e.g. identification of patients appropriate for lifestyle intervention), opportunity (e.g. mode of delivery) and motivation (e.g. professional responsibility); themes mapped to 6 TDF domains. 34 BCTs were identified across the suggested interventions. This systematic review found that several interacting factors influence lifestyle in people with infertility as well as health professional behaviour with regards to provision of lifestyle interventions for infertility. These factors can be targeted for optimisation of interventions. In light of the limited number of qualitative studies, there is a need for more qualitative research to gain deeper insights into the perspectives of people with infertility and health professionals for further exploration of the complex and interacting factors which shape lifestyle during the fertility journey.

Although food insecurity affects a significant proportion of young children in New Zealand (NZ)(1), evidence of its association with dietary intake and sociodemographic characteristics in this population is lacking. This study aims to assess the household food security status of young NZ children and its association with energy and nutrient intake and sociodemographic factors. This study included 289 caregiver and child (1-3 years old) dyads from the same household in either Auckland, Wellington, or Dunedin, NZ. Household food security status was determined using a validated and NZ-specific eight-item questionnaire(2). Usual dietary intake was determined from two 24-hour food recalls, using the multiple source method(3). The prevalence of inadequate nutrient intake was assessed using the Estimated Average Requirement (EAR) cut-point method and full probability approach. Sociodemographic factors (i.e., socioeconomic status, ethnicity, caregiver education, employment status, household size and structure) were collected from questionnaires. Linear regression models were used to estimate associations with statistical significance set at p <0.05. Over 30% of participants had experienced food insecurity in the past 12 months. Of all eight indicator statements, “the variety of foods we are able to eat is limited by a lack of money,” had the highest proportion of participants responding “often” or “sometimes” (35.8%). Moderately food insecure children exhibited higher fat and saturated fat intakes, consuming 3.0 (0.2, 5.8) g/day more fat, and 2.0 (0.6, 3.5) g/day more saturated fat compared to food secure children (p<0.05). Severely food insecure children had lower g/kg/day protein intake compared to food secure children (p<0.05). In comparison to food secure children, moderately and severely food insecure children had lower fibre intake, consuming 1.6 (2.8, 0.3) g/day and 2.6 (4.0, 1.2) g/day less fibre, respectively. Severely food insecure children had the highest prevalence of inadequate calcium (7.0%) and vitamin C (9.3%) intakes, compared with food secure children [prevalence of inadequate intakes: calcium (2.3%) and vitamin C (2.8%)]. Household food insecurity was more common in those of Māori or Pacific ethnicity; living in areas of high deprivation; having a caregiver who was younger, not in paid employment, or had low educational attainment; living with ≥2 other children in the household; and living in a sole-parent household. Food insecure young NZ children consume a diet that exhibits lower nutritional quality in certain measures compared to their food-secure counterparts. Food insecurity was associated with various sociodemographic factors that are closely linked with poverty or low income. As such, there is an urgent need for poverty mitigation initiatives to safeguard vulnerable young children from the adverse consequences of food insecurity.

The estimated global preterm birth rate in 20201 was more than 10% of livebirths or 13.4 million infants. Nutrition in the neonatal period is a key factor to optimise growth, neurodevelopment, and later metabolic disease risk2. There is no consensus on optimal nutrition for preterm infants, leading to substantial practice variation3. We aimed to assess the quality of nutritional guidelines for preterm infants, the consistency of recommendations, and the gaps in these recommendations. This review is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 checklist. The study protocol was registered with PROSPERO (CRD42022327248). We searched six databases and 44 websites for nutritional guidelines for preterm infants before first hospital discharge, which were endorsed, prepared, or authorised by a regional, national, or international body, written in English, and published between 2012-2023. Two reviewers independently screened articles and extracted relevant data including nutritional recommendations (ranges or descriptions), the quality of recommendations (certainty of evidence and strength of recommendation), and gaps in recommendations, defined as those identified by the guidelines or when recommendations were based on very low certainty evidence. Disagreements were resolved by discussion or a third reviewer. Four reviewers appraised the included guidelines using AGREE II. We identified 7051 records, 27 guidelines were included in the review, 26% of which were of high quality. Most guidelines lacked stakeholder involvement and rigour of development. Twelve guidelines had recommendations for macronutrient intake, 18 for micronutrient intake, 12 for feeding, eight for fortification, and 14 for monitoring of nutritional adequacy. Only two guidelines provided recommendations for all five of these aspects. We found considerable variation in recommendations, many of which lacked details of certainty of evidence and strength of recommendation. Recommendations for feeding types and breastmilk fortification were consistent among high quality guidelines, but recommendations varied for intakes of almost all nutrients and monitoring of nutritional adequacy. Different guidelines gave different certainty of evidence for the same recommendations. Most gaps in recommendations were due to a very low certainty of evidence. Future development of nutritional guidelines for preterm infants should follow the standard guideline development method and ensure rigorous process including stakeholders’ involvement to improve the reporting of strength of recommendation, certainty of evidence, and gaps in recommendation. Evidence is needed to support recommendations about macro and micronutrient intakes, breastmilk fortification, and markers on adequacy of intake of different nutrients.

Optimal nutrition is essential for preterm infants as they face many barriers to achieving exclusive breastfeeding (EBF) and successfully introducing complementary foods (CF)(1). There is limited evidence of early feeding practices of preterm infants in Aotearoa, New Zealand (NZ). We aimed to investigate the facilitators and barriers to EBF and CF introduction in preterm infants in NZ. A nationwide self-completed electronic questionnaire was disseminated via social media to mothers of preterm infants. The survey collected quantitative data on hospital feeding practices, breastfeeding rates, timing of CF introduction, and fussy eating behaviours. Relationships between feeding practices and maternal and infant characteristics, such as ethnicity and level of prematurity, were explored using the Chi-Square statistical test in SPSS. Qualitative information regarding mothers’ experiences with breastfeeding, CF introduction, type of education and support received about the nutrition of preterm infants were collected for thematic analysis using Nvivo. The survey started in April and will close on 20th August 2023. Here we present preliminary findings of a subset of responses collected to date, and full results will be available for the conference. Up to 1st August 2023, 201 mothers had completed the survey. Most mothers self-identified as of New Zealand European (58%) and Māori (13%) background. Most infants (39%) were older than 12 months of chronological age (CA) and born moderate or late preterm (32+0 – 36+6 weeks’ gestation, 70%). Almost 50% of mothers required in-hospital supplementation of mothers’ milk (infant formula, 28% and donor breastmilk, 20%), and 44% of mothers were EBF at the time of hospital discharge. EBF for 5-6 months of CA was reported by 21% of mothers, and 46% provided any breastmilk for more than 6 months of CA. Among mothers who had introduced CF (n = 138), 74% reported introducing CF between 5-8 months of CA, and the infant’s first foods were primarily vegetables (65%) and fruits (60%). Fussy eating behaviour was reported by 47%, and food fussiness was significantly associated with a decreased frequency of vegetable (p<0.001) and fruit (p = 0.004) consumption. Challenges with breastfeeding included the infant’s feeding difficulties, low milk supply, maternal stressors, lack of support and education from health professionals. Challenges to CF introduction included fussiness and maternal fears such as choking and lack of confidence. Support from lactation consultants and previous experience with introducing CF were the most common enablers for breastfeeding and timely CF introduction, respectively. Our findings provide the first insight into the early feeding practices of preterm infants in Aotearoa, New Zealand. This information will support strategies to improve the nutritional management of preterm infants by increasing awareness of common challenges mothers face to achieve the recommended breastfeeding guidelines and CF practices in this vulnerable population.

Monitoring indicators of children`s diet quality at the national level is imperative to examine if a country is on track to achieving children`s global nutrition targets and fulfilling the related Sustainable Development Goals. Despite the importance of diet quality in early life and its impact in health and wellbeing throughout the life course, Aotearoa New Zealand has limited information that is nationally representative or generalizable on children`s diet quality, especially among children under 5 years old. The only national child nutrition survey conducted to date took place two decades ago and involved children 5 years of age and older. We have previously used data collected by the Growing in Up in New Zealand cohort study, which is nationally generalizable, to partially fill historic gaps in knowledge of children`s diet and feeding practices in the first five years of life. Information on breastfeeding initiation, duration and exclusivity, timing of food introduction and whole-of-diet adherence to National Food and Nutrition Guidelines have been previously published 1–3. This work intends to complement information on NZ children`s diet quality by examining the cohort`s dietary patterns (DPs) at 9- (n = 6,259), 24- (n = 6,292), and 54-months (n = 6,131) and their maternal sociodemographic and health behaviour determinants. At all time-points, children`s DPs were identified using principal components analyses. Multivariate linear regressions were performed to examine the associations between each DP and the maternal variables. At 9-, 24- and 54-months two distinct DPs were identified, explaining, 36.4%, 35.3% and 33.6% of children`s intake variability, respectively. The Refined high in sugar and salt DP, at all time-points, was characterised by high positive loadings in white/refined breads and cereals and items with high content of sugar, sodium, and fat. At 24-months, the Refined high in sugar and salt DP also had high positive loading in the protein group. The Fruit/Vegetables DP, at all time-points, had high positive loadings for fruits and vegetables (with type varying across time-points). The Fruit/Vegetables DP had high loading in whole grain options of breads and cereals at 24-months and positive loading in the protein group at 9- and 54-months. High scores on the Refined high in sugar and salt DP at the three time-points were associated with maternal smoking habits, maternal education level, ethnicity, and maternal scores in the “Junk” and “Traditional/White bread” DPs (obtained at the antenatal maternal interview). High children’s scores on the Fruit/Vegetables DP, at all time-points, were associated with the maternal antenatal score in the “Health Conscious” DP. Findings support that policies and interventions aiming to improve early life diets in NZ should be culturally safe and support mothers’ access to formal education, healthy diets, and smoking cessation.

Young children, especially those under one year of age, are at higher risk of choking on food due to their body’s immature physiology and chewing, swallowing and coughing ability(1). In 2020, the Ministry of Education mandated the Ministry of Health’s food-related choking guidance for babies and young children at early learning services (ELS), adding it to the licensing criteria(2). Some ELS managers reported that this policy may negatively influence the food and nutrition environment within ELS(3).This study aimed to assess the impact of the food-related choking policy on the food and nutrition environment within ELS. Data were collected using an online Qualtrics questionnaire from ELS in four District Health Board regions: Waikato, Bay of Plenty, Lakes, and Auckland (N = 1066), sourced from the Ministry of Education, Education Counts database. Responses were received from 179 ELS (17%) and most reported making changes due to the food-related choking guidance. The main changes were to the food provided by the ELS (75%), education for whānau/family (73%), and supervision of children (70%). Over half of the centres reported adjusting staff duties to allow for increased supervision of eating (60%) and changed/ceased celebrations or fundraisers (58%). Over half of the respondents (55%) reported that changes to reduce the risk of food-related choking had affected the ‘cultural kaupapa’ (plan/policy) of the ELS. A key theme from written responses was that centres had ‘not come together as whānau’, which refers to reduced hosting of centre events/celebrations within the centre and externally with children and whānau (families). The main reason appeared to be that the food restrictions in the guidance made the management of ‘shared kai (food)’ too difficult. Approximately two-thirds of centres (61%) reported removing foods from menus, and around half (49%) modified the texture of foods. Fifty-one per cent of ELS reported that there had been no change in parent-supplied food. The main foods removed from ELS menus were fruit, vegetables, hard crackers, sausages/other meats, and popcorn. Soft fruit, e.g., canned fruit, soft crackers, and soft meats (hamburger patties, mince, luncheon, and ham), were the main foods added to menus. ELS have responded to most of the new food-related choking guidance requirements regarding food provision, texture modification, and supervision; however, some ELS may need support to implement fully. Ceasing shared kai events at ELS has reduced opportunities to engage with whānau and limits cultural expression, connection and reciprocal learning and teaching about food and nutrition between the centre and whānau as outlined in Te Whariki Early Childhood Curriculum. Improved communication and support for parents and ELS to implement the recommendations for home and centre-supplied foods is needed. Together with sufficient funding for supervision and nutrition education to support children’s learning and cultural needs around food.

The prevalence of childhood obesity is increasing globally(1). While BMI is commonly used to define obesity, it is unable to differentiate between fat and muscle mass, leading to calls to measure body composition specifically(2). While several tools are available to assess body composition in infancy, it is unclear if they are directly comparable. Among a subset of healthy infants born to mothers participating in a randomised controlled trial of a preconception and antenatal nutritional supplement(3), measurements were made at ages 6 weeks (n = 58) and 6 months (n = 70) using air displacement plethysmography (ADP), whole-body dual-energy X-ray absorptiometry (DXA), and bioelectrical impedance spectroscopy (BIS). Estimates of percentage fat mass (%FM) were compared using Cohen’s kappa statistic (κ) and Bland-Altman analysis (4,5). There was none to weak agreement when comparing tertiles of %FM (κ = 0.15–0.59). When comparing absolute values, the bias (i.e., mean difference) was smallest when comparing BIS to ADP at 6 weeks (+1.7%). A similar bias was observed at 6 months when comparing DXA to ADP (+1.8%). However, when comparing BIA to DXA at both ages, biases were much larger (+7.6% and +4.7% at 6 weeks and 6 months, respectively). Furthermore, there was wide interindividual variance (limits of agreement [LOA] i.e., ± 1.96 SD) for each comparison. At 6 weeks, LOA ranged from ± 4.8 to ± 6.5% for BIA vs. DXA and BIA vs. ADP, respectively. At 6 months, LOA were even wider, ranging from ± 7.3 to ± 8.1% (DXA vs. ADP and BIA vs. DXA, respectively). Proportional biases were apparent when comparing BIS to the other tools at both ages, with BIS generally overestimating %FM more among infants with low adiposity. In addition to differences according to tool type, within-tool factors impacted body composition estimation. For ADP measurements, the choice of FFM density reference (Fomon vs. Butte) had minimal impact; however, choice of DXA software version (GE Lunar enCORE basic vs. enhanced) and BIS analysis approach (empirical equation vs. mixture theory prediction) led to very different estimates of body composition. In conclusion, when comparing body composition assessment tools in infancy, there was limited agreement between three commonly used tools. Therefore, researchers and clinicians must be cautious when conducting longitudinal analyses or when comparing findings across studies, as estimates are not comparable across tools.

Carotenoids, a group of phytochemicals found in plant-based foods with yellow, red, or orange pigments, have been shown to be stored in the skin upon consumption of carotenoid-rich foods(1). Skin carotenoid levels can be measured using skin reflectance spectroscopy, which assesses skin lightness (L*), redness (a*), and yellowness (b*)(2). Previous research has demonstrated significant increases in skin yellowness (b*) after a 4-week high-carotenoid diet(2). The aim was to examine shorter-term changes (two weeks) in skin yellowness following the consumption of a Healthy Australian Diet rich in carotenoids compared to a Typical Australian Diet with low carotenoid content. The study analysed data from an eight-week randomised, cross-over feeding trial involving 34 adults (53% female, aged 38.44 ± 18.05 years). Participants were randomly assigned to each diet for two weeks, separated by a two-week washout period. The Healthy Australian Diet adhered to the Australian Dietary Guidelines(3), emphasising the consumption of carotenoid-rich fruits and vegetables such as carrots, pumpkin, tomatoes, red capsicum, and sweet potatoes. In contrast, the Typical Australian Diet was formulated based on apparent consumption patterns in Australia(4) and emphasised the intake of fruits and vegetables low in beta-carotene, such as white potatoes, onions, cauliflower, and pears. Skin carotenoids were measured using skin reflectance spectroscopy at three sites (palm, inner and outer arm), and each measurement was taken thrice. Overall skin yellowness (b*) was calculated as the average of all three measurements at all three sites. Measurements were conducted at four key visits: week 0 (end of run-in; baseline 1), week 2 (post-feeding phase 1), week 4 (end of washout; baseline 2), and week 8 (post-feeding phase 2). Differential changes in skin carotenoid levels between intervention groups were assessed using linear mixed-effect models, adjusting for diet sequence, feeding phase, body fat percentage, total fat intake, and subject ID as a random variable to account for potential autocorrelation. Post-hoc pairwise comparisons were conducted to evaluate the relative effects of each diet. Although there was a trend towards higher skin yellowness (0.215 ± 0.517; p = 0.41) following consumption of the Healthy Australian diet relative to baseline, and an inverse trend following the Typical Australian Diet (−0.118 ± 0.539, p = 0.56), the difference in change between the two diets was not statistically significant (p = 0.32). Notably, baseline values within this participant cohort were higher than previously reported at b* = 16.7(1) (baseline 1 b*: 17.57 ± 2.23, baseline 2 b*: 17.71 ± 2.26), which may influence the magnitude of observable change. The findings suggest that the two-week intervention duration may be insufficient to achieve statistically significant changes in skin carotenoid levels. Future investigations into whether plasma carotenoids increase first, with skin changes occurring later, could offer valuable insights into the potential utility of this as a biomarker validation of change in fruit and vegetable intake.

Snacking frequency has increased in recent years, with many snack options being nutrient-poor and likely contributing to excessive energy intakes (1,2). At the same time, nut intakes have remained low(3). While almonds, like many other snacks, are high in fat and energy, they are rich in beneficial unsaturated fats, fibre, vitamins, minerals, and phytonutrients. Snacking on almonds may offer substantial health advantages, including improving energy balance and overall diet quality, compared to typical modern snack foods. The healthier diets observed among nut consumers may be partially explained by addition of nuts to the diet leading to displacement of other, less desirable foods. We aimed to compare the effects of consuming a snack of almonds vs sweet biscuits or savoury crackers daily for one year on displacement of discretionary foods and food group patterns. We used a randomised controlled parallel study design involving 136 non-obese habitual discretionary snack consumers aged 18–65. Participants were randomly assigned to receive a snack of either almonds, or biscuits, daily for one year. These isocaloric snacks provided either 10% of participants’ total energy requirements or 1030 kJ (equivalent to 42.5 g almonds), whichever was higher. Dietary intake was measured using three-day weighed diet records record at baseline, 3, 6, and 12 months. Of the participants, 101 (74%) were female, with a mean (SD) age of 35.6 (13.4) years and BMI of 23.7 (3.0) kg/m2. Those assigned to the almond group increased their percentage total energy (%TE) from nuts and seeds from 1.4% (baseline) to 13.8% (12 months), while those assigned to the biscuit group increased %TE from biscuits and crackers from 5.1% to 12.4%. There was a non-statistically significant (p = 0.053) decrease in %TE from discretionary foods to 12-months for almond group compared to the biscuit group. %TE from discretionary foods decreased significantly in the almond group from baseline to 12-months (mean (95% CI) difference: −4.9% (−8.3, −1.5) p = 0.005), with no evidence of a change observed in the biscuit group (−0.0% (−3.6, 3.6) p = 0.994). Regular consumption of nuts as a snack food may improve diet quality by displacing discretionary food intake among regular discretionary snack consumers. However, the observed displacement was incomplete relative to the energy provided by the study snack. Snacking is driven by factors beyond simply satisfying hunger, including flavour, texture, and overall eating experience. We hypothesise that – among this group of discretionary snack consumers – partial displacement, and hence the continued consumption of other snack foods, was likely due to the sensory properties of consuming almonds alone being insufficient to fulfil hedonic satiation. Strategies to improve sensory appeal of almonds to discretionary snack consumers may assuage subsequent snack-seeking behaviour and provide important advantages in terms of both energy balance and diet quality.

Nut consumption in Australia does not meet recommended levels, and concern regarding the impact of nuts on body weight is a reported barrier to regular intake, due to their high energy content(1). Nut intake is not associated with higher body weight(2), which may be explained by their lower metabolisable energy(3). Hence, total energy intake may be overestimated among nut consumers. Nut consumption patterns in Australia are also unknown. This study aimed to describe the metabolisable energy from nuts, and nut consumption patterns of the Australian population. A previously developed nut-specific database was expanded to include the metabolisable energy of nuts based on nut type and form, and applied to the 2011-12 National Nutrition and Physical Activity Survey (NNPAS). Mean metabolisable energy was compared to mean energy intake determined using Atwater factors for nut consumers. Additionally, nut consumption patterns were also explored, including the proportion of nuts consumed at meals and snacks, proportion of nuts consumed alone or combined with other foods, and timing of nut intake. Among nut consumers, the mean metabolisable energy from nuts, based only on nut type, was 241.24 (95% CI: 232.00, 250.49) kJ/day. The mean metabolisable energy when considering both nut type and form was 260.69 (95% CI: 250.18, 271.21) kJ/day, while energy from nuts using Atwater factors was 317.60 (95% CI: 304.85, 330.35) kJ/day. Nuts were more likely to be consumed as snacks, with approximately 63% of all nut intake (in grams) occurring as a snack. Nuts were frequently consumed with other foods and beverages, with only 27% of nuts consumed alone or with plain water. Furthermore, nuts were most often consumed after midday (68% of intake) rather than in the morning (32% of intake). Application of metabolisable energy data to the 2011-12 NNPAS has a significant impact on the calculation of energy intake from nuts. Nut consumption patterns identify most nut consumption occurring as snacks and two-thirds of nut intake occurring in the afternoon and evening. These findings may inform strategies to promote nut consumption in Australia.

Lockdown measures imposed in Australia to slow the transmission of COVID-19 protected most Australians from the virus(1). In some areas in NSW, specifically Western Sydney areas, more stringent lockdown regulations were implemented from July to September 2021, referred to as local governmental areas (LGAs) of concern(2). Preliminary evidence showed that people’s lifestyle such as dietary and physical activity behaviours and mental health during lockdown were altered from before lockdown(3). However, intermediate and longer-term impacts on nutrition and physical health are unclear, especially in LGAs of concern. We aimed to examine the impacts of the lockdown on nutritional behaviour of residents of Western Sydney. Mixed methods were employed including quantitative surveys such as ASA-24 and qualitative focus groups, using R software for quantitative analysis. Data was collected from 523 survey participants in addition to 42 focus group participants. The sample was representative of age, gender, county of birth and area of residence. Sixty-two percent reported decreases in their physical activity level post-lockdown compared with pre-lockdown, and 15% reported increases in their physical activity level post-lockdown compared with pre-lockdown. Sixty-nine percent reported increases in their physical activity levels post-lockdown compared with during the lockdown, and 12% reported decreases. Self-reported weight increased in 50% of the participants post-lockdown compared with pre-lockdown and decreased in 13% of the participants. Forty percent self-reported a decrease in their body weight post-lockdown compared with during the lockdown while 16% self-reported an increase in their body weight post-lockdown compared with during the lockdown. Food security status was reported as much worse in seven percent of the participants post-lockdown compared with pre-lockdown while being unvaried in 93% of the participants. Food security status remained unvaried post-lockdown compared with during the lockdown in 93% of the participants but much better in six percent. Eating habits were self-reported as much worse by 52% of the participants post-lockdown compared with pre-lockdown and much better by nine percent. Forty-eight percent of the participants self-reported their eating habits as much better post-lockdown compared with during the lockdown and 10% as much worse. COVID-19 lockdown negatively impacted eating behaviours, physical activity and body weight of Western Sydney residents with minimal impacts on food security. Further analyses are required to examine the associations between eating patterns, physical activity, body weight and food security and age, gender, country of birth and area of residence of participants. These findings can later be used to draft policies that can be put in practice in case of future pandemics in Australia, or in the case of other common natural disasters, such as bushfires and floods.

Diet and diet quality have been linked to improvements to psychosocial health and wellbeing(1). However, data from national health surveys indicate that most Australian’s have poor diet quality and consume a Western style diet high in saturated fat, discretionary foods and added sugars and salt(2). The Mediterranean Diet (MedDiet), a predominantly plant-based diet rich in bioactive foods and nutrients, has been shown to improve mood and wellbeing. However, long-term effects beyond 6-months have not been thoroughly explored in older adults. MedWalk compares a 12-month MedDiet and Walking intervention with habitual lifestyle (HabDiet) in 160 older adults residing in retirement villages across South Australia and Victoria. Data from the South Australian cohort at baseline (n = 83) and 6-months (n = 74) are presented in this preliminary analysis.

To determine dietary compliance, participants completed the 14-point MedDiet Adherence (MEDAS) questionnaire which assesses the intake of key MedDiet foods such as legumes, fish, and extra virgin olive oil; higher scores reflect higher adherence. Wellbeing was assessed using the Flourishing Index, which assesses life satisfaction, relationship satisfaction, happiness, mental and physical health. The total flourishing score includes 10 questions with a maximum of 100 points reflecting highest flourishing, while the secure flourishing score includes two additional questions related to safety, housing, and access to food with a maximum of 120 points to indicate highest flourishing. Group and time interactions for MEDAS and flourishing scores were analysed using linear mixed effects modelling. There were no significant differences between groups for MEDAS score at baseline (MedDiet 5.78 ± 0.34 vs HabDiet 5.74 ± 0.32). At 6 months, the MedDiet group had significantly increased their MEDAS by 4.16 points (P<0.001), (MedDiet 10.0 ± 0.42 vs HabDiet (5.85 ± 0.39). At baseline there were no significant differences between groups for the total 10-point flourishing score (MedDiet 83.5 ± 2.01 vs HabDiet 82.1 ± 2.0) or 12-point secure flourishing score (MedDiet 100.6 ± 2.2 vs HabDiet 100.4 ± 2.2). At 6 months there was a significant between-group difference in total flourishing index scores with a mean difference of 6.97 points in the MedDiet group (MedDiet 85.8 ± 1.9 vs HabDiet 78.8 ± 1.8, P = 0.010). Similarly, the secure flourishing index score was 6.18 points higher in the MedDiet group compared to the HabDiet at 6-months (MedDiet 102.9 ± 2.2 vs HabDiet 96.8 ± 2.07, P = 0.046). Adhering to a MedDiet and walking intervention may lead to positive improvements to wellbeing in an older population. The flourishing index may need to be compared with other wellbeing questionnaires and instruments to better understand the relationship between wellbeing and MedDiet adherence as there was a cross-sectional association but no positive correlation at 6-months.

Snacking is a common eating behaviour among adolescents accounting for more than a quarter of their total energy intake but the relationship between snacks and overall diet quality remains unclear(1). Hence, the aim of this study was to examine characteristics of snacks among Australian adolescents (12-18 years) according to their level of diet quality. This secondary analysis uses one day of 24-hour dietary recall data from the 2011 - 2012 National Nutrition and Physical Activity Survey (n = 935). Snacks were defined based on participant-identified eating occasions(2). The Dietary Guideline Index for Children and Adolescents (DGI-CA) was used to assessed adherence to the Australian Dietary Guidelines(3), with the highest tertile of the DGI-CA score indicating high adherence. The means (95% confidence intervals [CI]) for daily snack frequency and snack energy density (ED; kJ/g) were estimated for boys and girls, using linear regression, adjusted for age, area-level disadvantage, and energy misreporting. The differences in means and proportions across tertiles of DGI-CA scores were tested by using F- and Chi square-tests, respectively. The results show no significant differences in the mean frequency of snacks across tertiles of DGI-CA scores in either boys (lowest tertile mean = 2.2, 95% CI [2.0, 2.4] snacks/day, highest tertile = 2.1 [1.9, 2.3]) or girls (lowest tertile = 1.9 [1.7, 2.1] snacks/day, highest tertile = 2.2 [1.9, 2.4]). The mean ED of snacks decreased as DGI-CA scores increased in both boys (lowest tertile = 8.42, 95% CI [7.1, 10] kJ/g, highest tertile = 6.32 [5.4, 7.4] kJ/g) and girls (lowest tertile = 8.99 [7.8, 10.3] kJ/g, highest tertile = 5.92 [5.1, 6.9] kJ/g). As DGI-CA scores increased, the proportion of both boys and girls consuming discretionary foods at snacks (such as soft drinks) decreased, while foods from the five food groups (such as apples) increased (p-values < 0.05). In conclusion, snack ED, but not frequency, and the types of foods consumed by adolescents at snacks varied by a level of diet quality. Snack ED decreased with increasing diet quality and adolescents with higher diet quality had higher intakes of foods from the five food groups and lower intakes of discretionary foods at snacks. Encouraging the consumption of lower-ED foods from the five food groups at snacks presents an opportunity to enhance adolescent diet quality. Future studies should explore snack-specific strategies to improve overall diet quality of adolescents.

The Mediterranean diet (MedDiet) is largely a plant-based dietary pattern which is associated with a reduced risk of numerous chronic diseases(1,2). A traditional MedDiet contains a wide variety of wild herbs and spices, which are frequently used in cooking and food preparation(3,4), and are a valuable source of antioxidants. However, little is known about herbs and spices use in Australian households. Therefore, the aim of this study was to determine the types of herbs and spices used in cooking and food preparation in Australian households. A cross-sectional study was undertaken amongst Australian adults aged ≥18 years. Participants were recruited via social media platforms requesting voluntary participation in an online survey. The survey tool included questions related to the types of herbs and spices used and consumed in Australian households, frequency of use, and the perceived level of confidence for use of herbs and spices in cooking and food preparation. Given the lack of a previously validated and reliable survey instrument, the authors developed a prototype questionnaire that was initially piloted against a separate representative sample for face validity. A total of n = 400 participants responded and completed the survey. Participants were mostly female (n = 340; 85.0%) with a mean age of 46.5 ± 14.7 years and were overweight (BMI: 26.4 ± 6.0 kg/m2). In the previous 12 months, two-thirds of participants (n = 258; 64.8%) reported consuming herbs and spices 1-2 times per day, which were most commonly consumed as part of lunch or dinner meals (n = 372; 94.2%). Basil (n = 391; 97.8%), pepper (n = 390; 97.5%), and garlic (n = 387; 96.8%) were the most frequently used and consumed herbs and spices. A quarter of participants reported using basil 1-3 times per month (n = 104; 26%), while a quarter reported using pepper (n = 104; 26%) and garlic (n = 103; 25.8%) daily. The majority of participants identified that they were extremely confident (n = 159; 39.8%) or very confident (n = 149; 37.3%) using herbs and spices in cooking and food preparation. Most participants (n = 282; 70.5%) reported growing herbs and spices in their own homes. This cross-sectional analysis of Australian households shows that most Australian adults consume herbs and spices daily, with basil, pepper, and garlic being the most frequently consumed. Further investigation into the quantities needed to elicit potential health benefits of herbs and spices when incorporated into a healthy dietary pattern warrants future research.

Consumer interest in plant-based diets has increased, alongside significant growth in the availability of plant-based meat and dairy alternatives in supermarkets(1). The nutritional profile of these products is likely to vary due to the broad range of ingredients used(2). Food composition databases, such as the Australian Food Composition Database (AFCD), are used extensively in research, practice, and policy, including by nutrition and dietetics researchers and health professionals to identify the nutrient content of foods. However, it is unclear if, and to what extent, the AFCD data on plant-based alternatives reflects the current food supply. This study aimed to examine the range and composition of plant-based meat and dairy alternatives available in Australian supermarkets and compare this with the AFCD. Data on core plant-based meat and dairy alternatives were collected from eight Melbourne supermarkets between June and October 2022 using the CSIRO FoodTrackTM database methodology(3). Products were included if they were i) meat or dairy substitutes outlined in the AFCD; or ii) plant-based alternatives for core meat and dairy included in the Australian Dietary Guidelines. Product images were taken, and data was transcribed. Products collected in supermarkets were then ‘matched’ to the most appropriate reference item in the AFCD. In total, 455 meat alternatives (n = 219 legumes/pulses; n = 178 meat substitutes; n = 38 tofu/tempeh; n = 20 sausages) and 249 dairy alternatives (n = 157 milk; n = 52 cheese; n = 40 yoghurt) were identified. Over half of the plant-based meat substitutes (n = 102; 57%) were made from a soy/wheat/pea base protein. Of the dairy alternatives, just over half of the cheese substitutes had coconut as their main ingredient (n = 28; 54%), and almost two-thirds of yoghurts were coconut-based (n = 28; 70%). The majority of the 157 milks were oat-based (n = 57; 37%), followed by almond (n = 45; 29%), and soy (n = 27; 17%). Many supermarket products were not reflected in the AFCD, including over two-thirds of dairy alternatives (n = 159; 67%), and one-third of meat alternatives (n = 150; 33%). This was due to more product options within categories, such as the variety of canned beans/legumes (n = 96) and flavoured milk substitutes (n = 34) available in supermarkets, and a greater variety of main ingredients used, most notably for cheese substitutes (n = 52). This study highlights that the range of plant-based meat and dairy alternatives available in Australian supermarkets is diverse, with many different base ingredients used, and a great range of products available in-store than in the AFCD. Findings highlight the challenges of food composition databases in keeping up to date with the fast-growing plant-based sector. Outcomes from this study have implications for the monitoring of the food supply and population level dietary data.

Sports foods are formulations of protein powders, carbohydrate gels and other nutrients such as creatine and pre work out, that are designed for athletes to provide additional nutrients for optimum performance(1). These contain specific amounts of nutritive substances not meant for non-athletes(2). However, over the last decade there has been a substantial increase in the availability, types, and sales of sports foods in mainstream retailers(3,4), likely driven by non-athlete consumption. Increased consumption could lead to nutrient intake above recommendations(5) or unwanted side effects (e.g. caffeine overload) due to consumption of multiple products(6). Little is known about the characteristics and motivations of non-athletes and it is important to understand the drivers of this increase, to ensure appropriate and safe consumption. This study aims to investigate characteristics and motivations, consumption patterns, exercise participation, reasons for product selection and perception of risks and side effects of non-athlete sports food consumers. In 2022, non-athlete Australian adults (18-65) completed a purpose designed online cross-sectional survey. Closed ended questions collected demographic characteristics, sports food consumption (type, frequency, amount, cost), exercise participation (type, frequency, duration), purchase location, recommendation source (friends, family social media) and use of packaging attributes (e.g. claims) to inform decision making. Open-ended questions captured reasons for consumption, perceptions of any risks and side effects experienced. Descriptive statistics were performed for participant characteristics and open-ended questions were analysed using inductive thematic analysis. Participants (n = 307) were predominately female (56%), middle aged (45%), moderate income earners (53%) and tertiary educated (54%). Protein products were most consumed (powder 82%, bar 61%, snack 37%), with over two thirds (65%) consuming 2 or more products. Walking was the most frequent exercise performed (65%), supermarkets the most common purchase location (52%) and media the most frequent recommendation source (39%), with on-pack nutrition information being used by most respondents (95%) to inform product selection. Just over half (52%) stated perceived risks and more than a third (35%) reported experiencing side effects from sports food consumption. The main reasons for consuming sports foods were for protein intake, muscle recovery, stamina and energy. The key risks stated were kidney/liver/organ effects, caffeine overdose and gut/digestion problems. The main side effects reported were bloating, tingling, anxiety (jitters, shaking, trembling), nausea or stomach upsets. Despite the consumer characteristics and their stated awareness of the risks, and side effects experienced, they continue to consume sports foods for their many perceived benefits. This is potentially driven by on-pack nutrition information and claims, which appear particularly influential in purchasing. Previous research shows that on-pack information can be inaccurate, or misleading(4). Tighter regulation and enforcement would benefit non-athletes, ensuring safer and more informed consumption.

Dietary strategies for weight loss typically place an emphasis on achieving a prescribed energy intake. Depending on the approach taken, this may be achieved by restricting certain nutrients or food groups, which may lower overall diet quality. Various studies have shown that a higher quality diet is associated with better cardiovascular (CV) health outcomes1. This study aimed to evaluate the effect of an energy restricted diet on diet quality, and associated changes in cardiovascular risk factors. One hundred and forty adults (42 M:98 F, 47.5 ± 10.8 years, BMI 30.7 ± 2.3 kg/m2) underwent an energy restricted diet (30% reduction) with dietary counselling for 3 months, followed by 6 months of weight maintenance. Four-day weighed food diaries captured dietary data at baseline, 3 and 9 months and were analysed using a novel algorithm to score diet quality (based on the Dietary Guideline Index, DGI)2. Total DGI scores ranged from 0-120, with sub scores for consumption of core (0-70) and non-core foods (0-50). For all scores, a higher score or increase reflects better diet quality. The CV risk factors assessed included blood pressure (SBP and DBP) and fasting lipids (total (TC), high and low-density lipoprotein cholesterol (HDL-C, LDL-C) and triglycerides (TAG). Mixed model analyses were used to determine changes over time (reported as mean ± standard error), and Spearman rho (rs) evaluated associations between DGI score and CV risk factors. Dietary energy intake was significantly restricted at 3 months (−3222 ± 159 kJ, P<0.001, n = 114) and 9 months (−2410 ± 167 kJ, P<0.001, n = 100) resulting in significant weight loss (3 months −7.0 ± 0.4 kg, P<0.001; 9 months −8.2 ± 0.4 kg, P<0.001). Clinically meaningful weight loss (>5% body mass) was achieved by 81% of participants by 3 months. Diet quality scores were low at baseline (scoring 49.2 ± 1.5), but improved significantly by 3 months (74.7 ± 1.6, P<0.000) primarily due to reductions in the consumption of non-core i.e. discretionary foods (Core sub-score +4.0. ± 0.7, Non-core sub-score +21.3.1 ± 1.6, both P<0.001). These improvements were maintained at 9 months (Total score 71.6 ± 1.7, P<0.000; Core sub-score +4.4 ± 0.7 from baseline, P<0.000; Non-core sub-score +17.9 ± 1.6 from baseline, P<0.000). There were significant inverse relationships between changes in Total DGI score and changes in DBP (rs = −0.268, P = 0.009), TC (rs = −0.298, P = 0.004), LDL-C (rs = −0.224, P = 0.032) and HDL-C (rs = −0.299, P = 0.004) but not SBP and TG at 3 months. These data emphasise the importance of including diet quality as a key component when planning energy restricted diets. Automated approaches will enable researchers to evaluate subtle changes in diet quality and their effect on health outcomes.