Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas(1). This research aims to describe the co-design of a digital intervention to improve vegetable intake with rural community members and research partners. Active participants in the co-design process were adults ≥18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process(2) was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population through eight online workshops and a 21-item online community survey between July and December 2021. Prioritisation methods were used to help workshop participants identify the ‘Must-have, Should-have, Could-have, and Won’t-have or will not have right now’ (MoSCoW) features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community. Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, ii) access to personalisation options and behaviour change support, and iii) improving the community food environment by providing information on and access to local food initiatives. Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This co-design process will inform the development of a prototype (evaluation phase) and feasibility testing (post-design phase) of this intervention. The resulting intervention is anticipated to reduce barriers and support enablers, across individual and community levels, to facilitate higher consumption of vegetables among rural Australians. These outcomes have the potential to contribute to improved wellbeing in the short term and reduced chronic disease risk in the long term, decreasing public health inequities.

Telehealth overcomes common geographical barriers to community/clinic-based healthcare and lifestyle interventions, (1,2) but whether it is a feasible and safe mode of healthcare service delivery for lifestyle-based interventions in those with non-alcoholic fatty liver disease (NAFLD) remains unknown. This study evaluated the feasibility and safety of a home exercise program with dietary advice to increase plant-based protein delivered and monitored by healthcare professionals via telehealth in adults with NAFLD. Secondary aims were to assess changes in macronutrient intake including protein from plant and animal sources, body weight, physical activity and physical function. This was a 12-week pilot feasibility randomised controlled trial conducted in 28 inactive adults (>45 years) with NAFLD. Participants were randomly allocated to receive: 1) a home-based, muscle strengthening exercise program (3 days/week) delivered and monitored remotely by an exercise physiologist using the TeleHab exercise platform/app (VALD Health) plus support from a nutritionist to increase daily protein intake to ~1.2-1.5 g/kg/day from predominately plant-based sources and behavioural change support delivered via 3-4 weekly text messages (Pro-Ex, n = 14) or 2) usual care (UC, n = 14). Feasibility was assessed via retention (defined as ≤10% attrition), adherence [≥66% to the muscle strengthening program and ≥80% to the recommended daily protein serves [total (≥3-3½), plant (≥2) and animal (≤1-1½) per day (via protein checklist)] and safety (intervention-related adverse events). Secondary outcomes included macronutrient intake (3x24-hour records), weight (self-reported), habitual physical activity (PA) [moderate-to-vigorous (MVPA), minutes/week via the Short International Physical Activity Questionnaire], and physical function [30-second sit-to-stand (STS) performance]. Since this was a pilot feasibility study, mean group differences (6 and 12-weeks) were estimated, with 95% confidence intervals, and standardised effects [Cohen D, effect size (ES)] reported for secondary outcomes. Overall, 25 participants (89%) completed the intervention. In Pro-Ex, mean adherence to the exercise program was 52%, while adherence to the recommended plant, animal and total protein serves/day was 32%, 42% and 14% of participants, respectively. One minor exercise-related adverse event occurred from 241 completed sessions over 12 weeks. Relative to UC, Pro-Ex experienced a mean 2.7 (95%CI: 0.9, 4.4; large ES d = 1.29) increase in 30-sec STS number, 46 minute (95%CI: −153, 245; small ES d = 0.19) increase in MVPA, 1.7kg (95%CI: −3.5, 0.2; moderate ES d = 0.54) decrease in body weight, 35.2g (95%CI: 11.0, 59.3; large ES d = 1.23) increase in protein and 8.3g (95%CI:-20.5, 4.0; moderate ES d=-0.57) reduction in saturated fat. In middle-aged and older adults with NAFLD, a home exercise and plant-based dietary protein intervention delivered via telehealth was safe, but not feasible in terms of achieving the desired level of adherence. Despite this, exploratory analysis indicates this mode of healthcare service delivery could play a role to support weight management and improve physical activity and physical function in adults with NAFLD.

Nutrition intervention trials play a key role in informing clinical and dietary guidelines. Within these trials, we need participants to change their behaviours; however, researchers seldom systematically consider how to support participants with these changes, contributing to poor adherence. Here we evaluate how using a behaviour change framework to develop support within a dietary intervention impacts young adults’ adherence to required trial behaviours. In the Protein Diet Satisfaction (PREDITION) trial, 80 young adults were randomised to a flexitarian or vegetarian diet for 10-weeks to investigate the psychological and cardiometabolic effects of moderate lean red meat consumption as part of a balanced diet(1). To understand these outcomes, it was key that participants within the trial (i) ate a healthy, basal vegetarian diet (excluding meat, poultry, and fish not provided by research team) and (ii) reported their dietary intake daily on a smartphone application (required to evaluate intervention compliance). To enhance adherence to these behaviours the Nine Principles framework was used to develop behaviour change support (BCS)(2). Key components of the BCS included access to a dietitian-led Facebook group, text reminders, and food delivery. Effectiveness was measured using the following analyses of the 78 participants who completed the study: pre-post change in targeted dietary habits over time using a subscore of the Healthy Diet Habits Index, adherence score to reporting over 10-weeks, Facebook group engagement, and impact evaluation. Analysis included linear imputation modelling, t-tests, and chi-square analysis. The total Healthy Diet Habits Index subscore out of 16 significantly increased from baseline to week 10 (10.6 ± 2.6 to 11.2 ± 2.6, p = 0.011), demonstrating maintenance of a healthy diet. Overall adherence to reporting was high across the 10 weeks, with the total population mean reporting score 90.4 ± 14.6 out of a possible 100. This strengthens study validity, allowing us to confidently report if participants complied with study requirements of consuming the intervention protein (red meat or plant-based meat alternatives) on top of a basal vegetarian diet. Although relatively low active Facebook engagement was observed (on average <1 ‘react’ per post), most participants agreed the text messages and Facebook groups supported them to adhere to recording (63%) and eating healthily (60%), respectively. This is the first study to provide an example of how a framework can be used to systematically develop, implement, and assess BCS within a nutrition trial. This appears to be a promising way to enhance adherence to study-related behaviours, including the burdensome task of reporting dietary intake. We believe this has great potential to improve research validity and decrease resource waste, not only for the PREDITION trial but in future dietary intervention trials.

For a qualified nutritionist to obtain registration with the Nutrition Society of Australia they must first demonstrate that they meet a set of competencies relating to required nutrition knowledge and skills(1). However, theoretical knowledge and a technical skillset may not be enough to actively contribute to the workforce as a new graduate(2). Employers have previously expressed a desire for nutrition graduates to also develop employability skills in undergraduate studies to be better prepared for the workforce(3). Universities across Australia appear to have heterogeneous approaches to building nutrition students employability skills. To better understand student workforce readiness and employability skills, the research team undertook a mixed-methods study. A validated work-ready tool was used to survey undergraduate nutrition students self-perception of work readiness (n = 88) and semi-structed interviews of students pre/post nutrition industry placements (n = 18) were conducted to assess factors impacting student understanding and development of work readiness. Preliminary data from the survey showed higher levels of perceived ability related to higher age in, written communication (P<0.05), decision making (P<0.05), working unsupervised (P<0.05) and managing challenges (P<0.05). Lower age showed lower perceived ability in understanding how to apply skills (P<0.001). Lower levels of work experience showed lower perceived ability to work in a team (P<0.01), collaborate (P<0.01), work under pressure (P<0.05), and identify problems (P<0.01). Thematic analysis from interviews revealed themes related to improved confidence following a placement experience, communicating to stakeholders, the importance of translation skills, the benefits of networking and self-efficacy. The results suggest there are numerous identified gaps and significant room for improvement. To have a systematic approach to skill development, universities training nutrition students should consider developing a framework that builds understanding and scaffolds skill development across year levels. An employability framework has the potential to increase students employability skills and knowledge, enhance student confidence and increase graduate employment.

Mentoring is an established method of promoting networking, professional growth and learning, and career development in many health professions(1). For a non-vocational profession such as nutrition with a diverse scope of practice, the impact of mentoring remains unclear. In 2020, the Nutrition Society of Australia (NSA) developed and implemented a mentoring program for registered nutritionists. The individually matched mentoring facilitates a 12-month relationship between nutritionists who opted-in to the program. This qualitative case study research aimed to understand the conceptualisation and development of the NSA mentoring program and explore the experience from the viewpoints of both mentors and mentees in the program. First, a 60-minute focus group was conducted with the NSA program organising committee to explore the initial conceptualisation, objectives of the program, expected outcomes, and related training provided to mentors and mentees. Then, a 34-item questionnaire was sent to 63 participants from the first three program cohorts to collect their demographic information as well as expectations, perception and experience of the mentoring. Twenty-one questionnaire responses from 10 mentors and 11 mentees were collected. Participants were from a range of nutrition professions across NSW, VIC, QLD, and WA. Ten questionnaire participants (four mentors and six mentees) further participated in in-depth interviews to provide narratives of their experience. Thematic analysis was conducted with employment of theory-building structure within the case study(2). Our findings indicated that despite an explicit discussion of mentoring focus on employability skills, e.g. communication, professionalism, advocacy, etc., many mentees perceived mentoring as a gateway to employment and career pathway development. The perceived benefits of mentoring were highly dependent on matching of mentor/mentee, which was complicated by the diversity of practice within the profession, and unstated expectations of individual mentees. Regardless of the perceived quality of their mentoring experience, participants reported that the NSA mentoring program added value to the society’s membership and were supportive of program continuity. In conclusion, the NSA mentoring program was a value-adding strategy to the society membership and it could play an important role in career pathway support into the diverse areas of practice in the nutrition profession. More explicit discussion of expectations between mentors and mentees at the beginning of mentoring could enhance the mentoring experience.

Private practice is the fastest growing employment sector for dietitians in Australia, including for new graduates(1). There is an anecdotal concern that current graduate cohorts are not adequately prepared for private practice. The present study aims to assess the existing literature relevant to workforce development specific to private practice dietetics, including areas such as workforce size, distribution, competency, practices and global challenges. The secondary aim is to identify gaps in the literature to inform future priority areas and to inform private practice dietetics workforce development research. Five databases were systematically searched from inception to August 2023 and grey-literature was searched using the Google search engine using key search terms to identify studies for inclusion. Of the 2361 peer-reviewed publications and 1800 grey literature, eighty were included. Directed content analysis and qualitative constant comparison technique were used to deductively extract data from eligible private practice literature. Intelligence sources covering the following themes proved to be limited: workforce size, distribution, attributes, demography, supply/preparation, competencies, continued professional development and challenges. However, clear structural issues present workforce challenges for private practice dietitians. There is an overwhelming paucity of comprehensive literature on the private practice dietetics workforce across the world. Private practice dietetics workforce development research is warranted to address current research gaps in a coordinated, collaborative approach to ensure this rapidly expanding workforce is well supported.

As the global population continues to age, strategies that promote health and wellbeing among older adults are urgently required. This demographic faces an increasing burden of chronic diseases linked to inflammation(1), often associated with diets that are energy dense and nutrient poor(2). Importantly, the impact of these conditions can be minimised by adopting an anti-inflammatory dietary pattern, such as the Mediterranean diet(3). While there are numerous predictors of behaviour and an individual’s capacity for behaviour change, nutrition knowledge is a fundamental influencer of eating behaviours(4). However, knowledge of anti-inflammatory diets generally and the Mediterranean diet specifically is lacking among older adults(5), highlighting the need for effective educational programs targeting this group. Digital health technologies have the potential to provide cost-effective and accessible nutrition education, however, few technologies have been developed to meet older adults unique needs and preferences. To address this gap, this study aimed to explore the specific needs and design preferences of older adults for an online nutrition education resource. A total of 20 adults aged 55 years and older participated in one of four 2-hour participatory design workshops, where prompted discussion questions were used to explore their use of technology and scope their needs and preferences for an online nutrition education resource. All participants were regularly using a range of different devices (e.g., smartphones, tablets, and computers) and reported being comfortable doing so. Participants wanted a website that could be accessed across devices (i.e., desktop and mobile friendly) that provided practical nutrition advice, recipes, and information on the link between diet and disease. A number of design principles were identified as essential to optimise the user experience, including large and simple fonts, use of dark type on a light background, and clear categories for easy navigation. To enhance engagement, participants sought a personalised resource that could be adjusted to suit their needs, provided up-to-date information, and allowed for easy content sharing with others, such as by exporting information as a PDF. Participatory design methods offer new knowledge for developing and refining existing and future digital health technologies that are appropriate and useful for the target audience. Specifically, the older adult participants were motivated to access a user-friendly web-based nutrition resource provided it was able to be personalised to their health and nutrition needs, offered practical solutions such as adaptations to portion size or in relation to cost, and was easily shareable with others. Given the limited availability of online, self-directed and evidence-based nutrition education resources for older adults, these findings provide valuable insights to shape digital health resources that cater to the needs and preferences of this population and have the potential to support healthy eating habits and contribute to reducing diet-related chronic disease burden.

Older adults in aged care homes account for 30% of the population burden of hip fractures(1). Nutritional interventions to correct protein and calcium inadequacies reduce these and other debilitating fractures, perhaps partly by reducing falls and slowing deterioration in bone morphology. We aimed to determine whether a nutritional approach to fracture risk reduction in aged care homes is cost-effective. Costing was estimated based on results of a prospective two-year cluster-randomised controlled trial involving 3313 residents in 27 aged care homes (intervention using high dairy menus), 3911 residents in 29 aged care homes (controls consuming from normal menus) and cost of ambulance, hospital, rehabilitation, and residential care incurred after fracture. The incremental cost-effectiveness ratios per fracture averted within a 2-year time horizon were estimated from the Australian healthcare perspective applying a 5% discount rate on costs after the first year. Intervention resulted in a total of 3.5 servings of milk, yoghurt and/or cheese daily, achieving 1,142mg calcium and 69g protein versus usual daily intakes of 700mg calcium and 58g protein consumed by controls. This intervention reduced all fractures by 33% at a daily cost of AU$0.66 per resident. The base-case results showed that intervention was cost-saving per fracture averted, with robust results in a variety of sensitivity and scenario analyses. Scaling the benefits of intervention to the Australian community equated to a saving of AU$66,780,000 annually in Australia and remained cost saving up to a daily food expenditure of AU$1.07 per aged care resident. Averting hip and other non-vertebral fractures in older adults in aged care homes by restoring nutritional inadequacies of protein and calcium is cost saving and supports the wide-spread implementation of this type of nutritional intervention in similar settings.

Centenarians represent a phenomenon of successful aging, yet little is known about their lifestyle and health practices, including diet/nutrition, medication use, and health conditions. A protocol for this systematic review was registered previously(1). We systematically searched Medline, CINAHL, Scopus, and grey literature from 2000 to 2022, limited to quantitative studies published in English among adults aged 95 years or above. Two reviewers independently screened 3,392 records and identified and extracted data from 34 eligible studies. Additionally, they independently assessed the study quality using the Modified Newcastle-Ottawa Scale (mNOS)(2). Any disagreement was discussed and resolved with a third reviewer. In analysis, pooled prevalence was provided for categorical variables on demographics, lifestyles, medications, and diseases using % (95%CI); mean or median was provided for continuous variables. Due to study heterogeneity, we conducted a narrative synthesis for the associations between the exposures and outcomes. Over 70% of the included studies met 6/8 criteria based on the mNOS; nearly half did not mention or control for confounders in statistical analyses. The age ranged from 95-118y (32 studies: 100y+; 2 studies: mean age 97-98 y); the majority were females (75%; 95%CI: 71%,78%). Most centenarians did not smoke or drink [current smokers: 7% (5%, 9%); former smokers:16% (12%, 19%); daily drinkers: 27% (20%, 34%); former drinkers:21% (13%, 30%)]. Most centenarians were physically inactive (23%; 20%, 26%). Over 50% had normal weight (52%; 42%, 61%), 33% (14%, 52%) underweight, and 14% (8%, 20%) overweight. Regarding nutrition, the narrative synthesis suggests that centenarians had normal levels of albumin (3.8g/dL), total triglycerides (111mg/dL), total (188mg/dL), and HDL cholesterol (54mg/dL) but high levels of LDL cholesterol (109mg/dL). Regarding medications, nearly 50% took antihypertensive medications (49%; 14%, 84%) or other cardiovascular drugs (48%; 24%, 71%); they took a median of 5 (range: 2-7) drugs. Common conditions included impairment of basic activities of daily living (ADL) (54%; 33%, 74%), hypertension (43%; 21%, 65%), and diabetes (22%; 9%, 52%). In regression analyses among centenarians, high dietary diversity, lower salt preference, and weight status were significant factors for more independence in basic ADL, lower mortality, and greater longevity. For example, a high dietary diversity score was associated with a low mortality risk [0.93 (0.92, 0.94) per unit increase]; those who preferred salty food versus those who did not had a 3.6-fold risk of impaired ADL [adj.OR: 3.59 (1.14, 11.25)]. Being overweight vs. normal weight reduced the risk of ADL impairment [adj.OR: 0.84 (0.78, 0.91] while underweight increased this risk [adj.OR:1.34 (1.28, 1.41)]. Also, overweight [adj.OR: 0.92 (0.90, 0.94)] or abdominal obesity [adj.OR: 0.72 (0.52, 0.996)] reduced the likelihood of longevity per kg increase. This systematic review suggests a healthy lifestyle, good nutrition, and normal body weight may contribute to extreme longevity. Interpreting these summary findings should be cautious due to potential recall bias and heterogeneity of the included studies.

The interplay between selenoproteins, oxidative stress, and cell death pathways holds promise in unravelling novel therapeutic targets for Alzheimer’s disease (AD) in the future. Nonetheless, further comprehensive investigations are warranted to fully comprehend the precise contributions of selenoproteins in the aetiology and potential therapeutic strategies for Alzheimer’s disease. Previous work into gene expression networks in AD has included analysis of the entire transcriptome and, as of yet, has not yielded consistent insight into pathological pathways.1 Despite the comprehensive assessment of the transcriptome enabled by current technologies, one drawback of the whole transcriptome analysis is the risk of overlooking subtle yet significant variations in metabolic pathways.2 Thus, we aimed to assess gene expression of known selenoprotein and selenium-containing pathways in two different brain regions (dorsolateral prefrontal cortex (DPC) and posterior cingulate cortex (PCC)) across the AD spectrum. We used RNA sequencing data from The Rush University’s Religious Orders Study and Memory and Aging Project (ROSMAP) cohort available in the AD Knowledge Portal (https://www.synapse.org/).3 This study included data available for a total of 889 DPC and 647 PCC samples. Four pathological phenotypes were determined based on pathology (CERAD) and clinical (CDR) status: AD ([(+) pathology, (+) clinical], prodromal disease, corresponding to donors that have not received a clinical diagnosis despite the presence of pathological alterations ([(+) pathology, (−) clinical], controls ([(−) pathology, (−) clinical] and non-AD dementia [(+) pathology, (+) clinical]. This last group was excluded from the analysis as it is assumed they may have been misdiagnosed or presented with non-AD dementia. Six selenium or AD-related pathways were assessed, accounting for 421 unique genes. Group comparisons were performed using linear mixed modelling adjusted for age, sex, APOEe4 status and batch via DESeq2 package with Benjamini-Hochberg adjustment for multiple testing. A total of 18 genes significantly differed between AD and controls in both brain areas (same direction in both brain areas; P < 0.05), including eight selenoprotein genes or genes directly associated with selenoprotein synthesis. Fifteen of them were also different (same direction) in PCC (seven selenoprotein/selenoprotein synthesis genes), and four were different in DPC (four selenoprotein/selenoprotein synthesis genes) between AD and prodromal. Only three genes significantly differed between prodromal and control samples (DPC), including the selenoprotein DIO3 and the transcription factor SP3. Our findings indicate a progressive change in gene expression across the different stages of AD. These findings shed light on critical genes involved in selenoprotein synthesis that play a role in AD pathogenesis. Restricting the analysis to a subset of pathways enabled the detection of smaller alterations between groups, which is particularly appropriate in trace element homeostasis, where small alterations may have significant downstream effects.

The role of protein in decreasing the risk of cardiometabolic diseases has been proposed, yet the findings are inconsistent, possibly due to how protein intake was expressed(1). This study aimed to examine how different ways of expressing protein intake may influence its relationships with diet quality and obesity. This study used data from the Australian National Nutrition and Physical Activity Survey (NNPAS) 2011-12, focusing on adults aged ≥19 years, excluding those who were pregnant or lactating, and had both anthropometric and dietary data (n = 7637). Total protein intake was assessed by up to two 24-hour dietary recalls and reported in two measurement units, namely g/day and % of energy intake. Usual protein (g) and energy intakes (kJ) were modelled using the Multiple Source Method(2). Diet quality was assessed using the Dietary Guidelines Index (DGI)(3). Body mass index (BMI) and waist circumference were used as measures of obesity. Multiple linear regressions were performed stratified by sex, and adjusting for age, country of birth, Socio-economic Indexes for Areas, physical activity level, energy misreporting, usual energy intake (for diet quality), and non-protein energy intake (for obesity). Positive associations between protein intake and diet quality were confirmed across measurement units. Protein intake expressed in % of energy intake (β-coefficient: men = 0.97; women = 1.21, p<0.001) had a higher β-coefficient than those reported in g/day (β-coefficient: men = 0.19; women = 0.30, p<0.001). Linear regression models showed a positive association between protein intake and BMI for men and women, either expressed in g/day (β-coefficient: men = 0.02, p<0.001; women = 0.03, p = 0.001) or % of energy intake (β-coefficient: men = 0.14, p<0.001; women = 0.12, p = 0.002). The relationship between protein intake expressed in g/day and waist circumference was also statistically significant (β-coefficient: men = 0.04, p = 0.004; women = 0.05, p = 0.035). However, protein intake expressed as % of energy intake was correlated with waist circumference for men only (β-coefficient: men = 0.26, p = 0.001; women = 0.19, p = 0.075). The consistent findings across measurement units suggested that the unit of g/day and % of energy intake can be used for examining associations between protein intake and diet quality. However, associations between protein intake and measures of obesity varied between protein units and sex. These findings suggest that the selection of protein measurement units in relation to obesity outcomes might need to consider the characteristics of study population (e.g., sex, energy intake). Overall, the outcomes of this study suggest that how protein is expressed may impact the associations between protein intake, diet quality, and obesity, and therefore require further considerations when examining the role of protein in cardiometabolic health.

Chronic pain affects 20-30% of people worldwide(1). While the impact of nutrition and dietary patterns on bodily pain has gained attention in recent years, the underlying linking mechanisms remain poorly understood; it is possible that body weight, specifically adiposity, may be a mediating factor(2). Thus, the primary aim of this study was to explore whether adiposity mediates the relationship between diet quality and bodily pain. This cross-sectional analysis included 654 adults (57% women, mean age 50.4 ± 1.1 years, BMI 29.0 ± 6.2 kg/m2) with complete diet, adiposity, and pain measures from the Whyalla Intergenerational Study of Health (2008-09). Diet quality was calculated using the Dietary Guideline Index (DGI total score, core and non-core scores)(3), and pain assessed via the Short Form-36 bodily pain scale (SF36-BPS) transformed percent score. Adiposity was determined from body mass index (BMI), waist circumference (WC), and body fat percent (BF, via dual energy x-ray absorptiometry). Mediation analyses determined the role of adiposity in the direct and indirect relationships between diet quality and pain in the whole population, then stratified by sex (self-report). There were no significant indirect or direct effects between DGI total scores and SF36-BPS, for any measure of adiposity. Direct effects were observed for DGI core-food scores on SF36-BPS for each measure of adiposity (BMI, β = 0.258, 95% CI 0.048, 0.467; WC β = 0.246, 95% CI 0.037, 0.455; BF β = 0.247, 95% CI 0.040, 0.454; all p<0.05). Each measure of adiposity accounted for <10% of the relationship between diet quality and pain, with a better-quality diet associated with less bodily pain (higher SF36-BPS). Relationships differed by sex; with no direct or indirect effects seen between DGI scores and SF36-BPS for men while, in women, there was non-mediation with direct positive effects between DGI total score and SF36-BPS for each measure of adiposity (BMI, β = 0.362, 95% CI 0.132, 0.591; WC β = 0.345, 95% CI 0.116, 0.574; BF β = 0.357, 95% CI 0.130, 0.584; all p<0.05). Also in women, body fat mediated 85% of the relationship between DGI non-core scores on bodily pain (indirect effect β=-0.242, 95% CI −0.358, −0.126, p <0.05). While adiposity did not mediate the relationship between diet quality and pain, this study highlights that diet quality plays a role in the pain experience with higher consumption of core foods showing direct associations with lower levels of bodily pain. Moreover, sex differences were observed, with less bodily pain in women associated with higher overall diet quality. Interestingly, body fat drove the relationship between higher pain scores and greater consumption of non-core foods (discretionary), but body fat alone was associated with consumption of fewer discretionary foods. This anomaly requires further investigation.

Vegan diet consumption is gaining popularity globally and in New Zealand. However, plant foods provide absent or limited quantities of important micronutrients such as vitamin B12, iron, zinc, and omega-three fatty acids(1). A restrictive and unplanned vegan diet may thus increase risks of nutrient deficiencies especially during pregnancy and early life if the nutrient demands are not fulfilled. Health professionals who provide primary support for pregnant women and their children are important figures in monitoring the nutritional statuses during the antenatal and postnatal periods(2). (Being knowledgeable about the nutritional risks of poorly-planned vegan diets, and having access to appropriate educational resources would support vegan mothers and children to achieve a well-balanced diet. Currently, there are insufficient studies investigating the perspectives of New Zealand’s health professionals within the realm of vegan diets during pregnancy and early life. The aim of the research is to utilise a mixed-methods approach to explore these concerns, attitudes, and experiences. Healthcare professionals, including dietitians, nurses, general practitioners and midwives were invited to participate in the study. Knowledge and attitude scores were collected with an online questionnaire and scores were recorded as a proportion of the participants. Subsequently, descriptions of experiences, concerns, and perspectives about the adoption of vegan diets during pregnancy and early life were collected with semi-structured interviews. A total of 14 health professionals completed the study. All health professionals showed positive attitudes towards the adoption of vegan diets during pregnancy but some exhibited greater concern about their restrictive nature especially in early childhood. Achieving intake adequacy and subjecting young children to intensive assessments for nutrient adequacy were among the concerns raised. More than 90% of health professionals were concerned about iron and vitamin B12 deficiencies while less than 50% were concerned about deficiencies in protein, omega-three fatty acids, iodine, zinc and vitamin D. Less than 50% of participants were aware that plant foods do not provide sufficient vitamin B12. More than 50% disagreed that sufficient information about vegan diets during pregnancy and early life is available. Insufficient evidence-based consensus and government guidelines, and limited access and referrals to dietitians for guidance on vegan diets were highlighted as challenges that reduce the overall knowledge and confidence. Hence, continual professional education and updated evidence-based resources would be important steps to support health professionals in providing guidance to individuals on vegan diets.

The nutritional environment in early life is a key factor for brain development and function. It is important to understand the relationship between early life nutrition and academic achievement in adolescence. The Pacific Islands families (PIF) birth cohort(1) were born in the year 2000. When their child was 6 weeks old mothers were asked questions concerning food security over the last year. Two binary measures of food security were derived as previously used in PIF and also by the Ministry of Health (MOH). Records of academic achievement for 649 youth were obtained from the National Certificate of Educational Achievement database in 2019. Highest qualifications and a composite ranking score allowed achievement to be assessed at levels 1, 2 and 3 of NCEA and for University Entrance (UE, lowest to highest). More females (27%) than males (18%) achieved UE as their highest qualification and more males (40%) than females (31%) achieved level 1 or 2 as their highest qualification. UE was achieved by 25% of those born into food secure households and 17% from food insecure households. Logistic regression demonstrated that being female increased the odds of achieving UE 1.8 fold and food security a further 1.6 fold. The prevalence of food insecurity was not different by sex but high at 29% and 42% using the PIF and MOH measure of food insecurity respectively. This work emphasises the importance of maternal and early life food security for subsequent academic achievement and the well-being of future generations.

Emerging evidence has indicated that perinatal exposure to low-calorie sweeteners (LCSs) might be associated with adverse pregnancy outcomes and offspring health(1). The aim of the study was to examine the patterns and predictors of LCS consumption among pregnant women in Australia. A web-based survey was conducted among 422 pregnant women aged 18-50 years between September and October 2022. Participants were recruited by a reputable consumer panel provider, Qualtrics. Sociodemographic, lifestyle, dietary intake (including LCS consumption), pregnancy-related characteristics, and participants’ awareness regarding the potential health effects of LCS were assessed. We assessed LCS consumption from twelve food groups that are common sources of LCS(2). To identify LCS consumption patterns and predictors of the patterns, a latent class analysis and hierarchical multinomial logistic regression was employed, respectively. The women’s mean (SD) age was 30 (4.6) years. Overall, 95% of the women reported consuming any LCS in the current pregnancy. Three different LCS consumption patterns were identified. Infrequent or non-consumers, representing 50% of the women, included those who rarely or never consumed LCS-containing foods and beverages (with a probability of less than 10%). The second pattern, moderate consumption, which encompassed 40% of the women, indicated low to moderate consumption of LCSs (for instance, the likelihood of consuming LCS-containing drinks ranged from 18% to 50%). The third pattern highlighted habitual consumption. These individuals (10%) had a high likelihood (ranging from 75% to 95%) of consuming foods from all food groups that contained LCS. The majority of women (71%) were unaware of the potential adverse effects of LCS, and only 25% expressed concerns about the potential impacts of LCS on their health and the health of their offspring. Moreover, women who frequently consumed sugar-sweetened beverages (SSBs) (≥2 times/week) or had gestational diabetes were over three times more likely to adopt a habitual LCS consumption pattern compared to those who consumed SSBs less often [adjusted relative risk ratio (aRRR) = 3.17, 95% CI: 1.39-7.21] and those without gestational diabetes [aRRR = 3.53, 95% CI: 1.03-12.10]. Additionally, having a medical condition was linked to a 55% lower chance of moderate LCS consumption compared to infrequent or non-consumption. These findings indicate LCS consumption is widespread, but awareness of its potential adverse health effect is low among pregnant women in Australia. Public health interventions to increase the awareness of potential adverse effect of LCS consumption, particularly among pregnant women with moderate and habitual consumption are warranted.

Evidence suggests that low carbohydrate eating patterns are effective for rapid weight loss 1, however, little is known about their long-term effects on the risk of chronic diseases. We assessed the association of a low carbohydrate diet score (LCD) with the incidence of type 2 diabetes using Melbourne Collaborative Cohort Study (MCCS) data. Between 1990 and 1994, the MCCS recruited 41,513 people aged 40 to 69 years. The first and second follow-ups were conducted in 1994-1998 and 2003-2007, respectively2. We analysed data from 39,185 participants. LCD at baseline was calculated as the percentage of energy from carbohydrate, fat, and protein. The higher the score the less carbohydrate contributed to energy intake. The association of LCD quintiles with the incidence of diabetes was assessed using modified Poisson regression, adjusted for lifestyle, obesity, socioeconomic and other confounders. LCD was positively associated with diabetes risk. Higher LCD score (p for trend = 0.001) was associated with increased risk of type 2 diabetes. Quintile 5 (38% energy from carbohydrates) versus quintile 1 (55% energy from carbohydrates) showed a 20% increased diabetes risk (incidence risk ratio (IRR) = 1.20 (95% CI: 1.05-1.37)). A further adjustment for BMI and WHR eliminated the association. Mediation analysis demonstrated that BMI attributed 76% of the LCD & diabetes association. Consuming a low carbohydrate diet, reflected as a high LCD score, may increase the risk of type 2 diabetes which is largely explained by obesity. Results imply the need for further studies, including clinical trials investigating the effects of a low carbohydrate diet in type 2 diabetes.

Stroke ranks as the world’s second leading cause of death and third in causing disabilities, a preventable disease affecting people of all demographics. Primary prevention is crucial to mitigate its impact by addressing modifiable risk factors such as poor diet, low physical activity (PA), obesity, smoking, high blood pressure (BP), elevated cholesterol, and blood glucose levels. This study evaluated quality of diet and other stroke modifiable risk factors among New Zealand (NZ) participants recruited at the baseline phase of the PERKS-International trial. PERKS is a Phase III, multicentre, prospective, pragmatic, open-label, single-blinded endpoint, two-arm randomised controlled trial conducted across Australia and NZ(1). Participants aged >35 and ≤75 years with ≥2 modifiable risk factors for stroke were assessed using the Life’s Simple 7 (LS7) score. LS7 includes seven components (BMI, BP, total cholesterol, blood glucose, dietary pattern, smoking, and PA) categorising into ideal, intermediate, and poor level. Height, weight, and BP were measured. Total cholesterol and blood glucose were measured via CardioChek PA Analyser. An online FFQ and Physical Activity Questionnaire were administered. Descriptive analyses and correlation coefficients were used to examine the characteristics of participants at the baseline. In NZ, out of 395 targeted participants, 375 (Female = 230, mean age = 57yrs) from diverse ethnic groups (NZ European = 204, Māori = 35, Pacific = 17) were recruited and assessed. Among LS7 metrics, smoking had the highest proportion of those in the ideal category (88%), followed by blood glucose (62%), total cholesterol (49%), dietary pattern (34%), BP (22%) and BMI (13%). Nearly 64% consumed <5 portions of fruits and vegetables per day. Almost half of the participants consumed beans and pulses less than once a week. About 43% and 31% consumed fibre-rich breakfast cereal and wholemeal bread less than once a week. Almost 10% drank fizzy drinks ≥4 times/week. Nearly 40% consumed sweets such as biscuits, cakes, and chocolate at least twice a week. Over half of the participants consumed red meat and chicken 2-3 times/week. In terms of other risk factors, over half of the participants were obese (BMI≥ 30 kg/m2). Only 12% were current smokers. About 10% drank alcohol 5-7 days/week. Physical activity expenditure (MET minutes/week) showed no significant sex difference. The LS7 factors correlated significantly were BMI and blood glucose (r = 0.157, p<0.01), total cholesterol and smoking (r=-0.129, p<0.01), BP and BMI (with a moderate correlation of r = 0.308, <0.001). The NZ participants in the PERKS-International trial, had poor diets, along with suboptimal lifestyle and biomedical stroke risk factors, reflecting the inclusion criteria for the study. Urgent action is required for the primary stroke prevention at population-level. The results of the trial, expected in 2024, will show the benefit of a mobile phone app on reducing these stroke risk factors.

Including nuts in the diet has been associated with improvements in cardiovascular disease (CVD) risk factors including high blood pressure (BP) and hyperlipidaemia (1–2). However, few studies have investigated if the same benefits exist for medicated and unmedicated populations. This systematic review and meta-analysis investigated the effects of nut intake on BP and lipids, with a sub-analysis evaluating response differences according to BP and lipid-lowering medication usage. MEDLINE, EMBASE, Scopus and Web of Sciences databases were searched for randomised controlled trials (RCTs) of longer than 3 weeks duration that assessed the effects of whole tree nuts or peanuts on BP and lipid responses. The American Diabetes Association Quality Criteria checklist was used to assess the risk of bias, and studies with a negative rating were removed from the meta-analysis. A random-effects meta-analysis was conducted, with subgroup analyses performed based on medication use (medicated, unmedicated, unreported, and mixed-use). Inter-study heterogeneity was estimated using the I2 test statistic. Data from 107 articles describing 98 studies (61 parallel, and 37 cross-over designs) were included in the meta-analysis. Overall, significant benefits of nut consumption were observed for triglycerides (TG) (mean difference [MD]: −0.11 mmol/L, 95% confidence intervals [CI]: −0.16, −0.06, p < 0.01, I2: 32.95%), total cholesterol (TC) (MD: −0.15 mmol/L, 95% CI: −0.22, −0.08, p < 0.01, I2: 61.84%), and low-density lipoprotein cholesterol (LDL-C) (MD: −0.12 mmol/L, 95% CI: −0.19, −0.06, p < 0.01, I2: 52.7%), but not high-density lipoprotein cholesterol, systolic BP, or diastolic BP. Among unmedicated populations, nut intake resulted in a significant decrease in TG (MD: −0.16 mmol/L, 95% CI: −0.30, −0.03, I2: 75.93%), and TC (MD: −0.21 mmol/L, 95% CI: −0.39, −0.03, I2: 86.59%), while in those with unreported medication use, there were significant decreases in TG (MD: −0.08 mmol/L, 95% CI: −0.15, −0.01, I2: 0%), TC (MD: −0.15 mmol/L, 95% CI: −0.22, −0.07, I2: 0%) and LDL-C (MD: −0.12 mmol/L, 95% CI: −0.19, −0.06, I2: 0.44%). No significant effects were observed for BP and lipids in the mixed medication group. While there were significant improvements in lipid profiles overall with tree nuts and peanuts consumption, we observed no benefits for BP. Furthermore, significant beneficial effects on lipids were only observed in those with unreported and no medication use. Few studies investigated effects in medicated participants only (n = 1 study for lipids), and the precise proportion of medication use within the mixed medicated group remains unclear. Consequently, it remains uncertain whether the lipid-lowering properties of consuming nuts remain when hyperlipidaemia is managed with medications. Further studies are needed to explore the influence of medication in combination with dietary approaches on responses to additional CVD risk factors.

People of Chinese ethnicity develop type 2 diabetes mellitus (T2DM) at a younger age and lower body mass index (BMI) than their Caucasian counterparts. Furthermore, Chinese migrants to Westernised countries have an increased risk of metabolic diseases compared to those in their country of origin(1,2). We propose that this increased risk is due to a greater manifestation of metabolic abnormalities in response to altered diet and lifestyle behaviours. Although fasting lipaemia and glycaemia are commonly used to predict risk of CVD and T2DM, assessment of impaired postprandial metabolism has been found to be a more sensitive indicator of risk(3). We hypothesised that Chinese migrants, at risk of T2DM, exhibit impaired postprandial lipid and lipoprotein metabolism compared to Australian-born Caucasian counterparts. Chinese and Caucasian adults at risk of T2DM were recruited to the study in which postprandial lipaemia and glycaemia were monitored following consumption of a high fat and high carbohydrate breakfast meal followed by a mixed, lunch meal. In a nonrandomised acute crossover trial, 15 adults (n = 8 Chinese and n = 7 Caucasian) aged ≥ 18 and ≤ 65 years at risk of T2DM (AUSDRISK score > 12 (median = 14.0, IQR = 3.0)), attended two postprandial test days separated by ≥ 7-day washout period. Test breakfast meals were isocaloric (3.6 MJ), high fat (46% energy from fat, 46% energy from carbohydrates) or high carbohydrate (74% E carbohydrates, 17.5% E fat). Blood samples were collected at baseline (fasting), 180 min and 360 min after consumption of the breakfast meal. The lunch meal (3.7 MJ, 18% E fat, 76% E carbohydrates) was consumed 240 min after baseline. Samples were analysed for lipaemia and glycaemia. Additionally, chylomicron-rich, and VLDL-rich lipoprotein fractions were isolated by sequential ultracentrifugation and chylomicron particle number (apolipoprotein (apo) B48), triacylglycerol (TAG), and total cholesterol were assessed in these fractions. Data were analysed using a mixed between-within-subject analysis of variance. There were no differences in age, and baseline anthropometric measures between groups, apart from the Chinese group exhibiting significantly lower waist circumference and BMI compared to the Caucasian group. There were no differences between groups in blood measures, apart from a higher total- and LDL-cholesterol concentration in the Caucasian compared to the Chinese group (P<0.05). Despite identical fasting TAG concentrations, the Chinese group, compared with the Caucasian group exhibited significantly elevated serum TAG and chylomicron-apo-B48 concentrations at 360 min following both test meals (P<0.01). All other postprandial measures were not different between groups. These findings show that despite having identical or improved fasting glycaemia and lipid profile, the Chinese group exhibited impaired postprandial lipid metabolism which may contributes to their increased risk of metabolic diseases.

Methods to reduce obesity and type 2 diabetes in Aotearoa New Zealand are desperately needed, with obesity one of the greatest predisposing factors for type 2 diabetes as well as heart disease, and certain cancers.1 A recent New Zealand report2 identified several interventions that might benefit people with established diabetes, the most promising being a period of rapid weight loss, followed by supported weight-loss maintenance. Such weight loss has shown to achieve what was previously thought impossible, diabetes remission,3 as well as appreciably reduce the risk of cardiovascular disease and prevent diabetes-related chronic kidney disease, retinopathy, nephropathy, and lower limb amputation.2 While the findings from the studies of low energy total meal replacement diets have stimulated great interest, their use in Aotearoa New Zealand has not been considered. The purpose of this primary-care led intervention therefore was to consider the acceptability and efficacy of such a weight loss programme, DiRECT, in Aotearoa New Zealand. Te Kāika DiRECT is a 12-month study conducted within a Māori primary healthcare provider in O¯tepoti Dunedin. The DiRECT protocol is three months of total meal replacement for rapid weight loss followed by food reintroduction and a longer period of supported weight loss maintenance. Participants were adults with prediabetes or T2 diabetes and obesity wanting to lose weight. Twenty participants (70% female, age 46 (SD 10), BMI 41 (9), HbA1c 51 (11)) were randomised to receive the DiRECT protocol, twenty more (70% female, age 50 (SD 8), BMI 40 (7), HbA1c 54 (14)) were randomised to receive best practice weight loss support (usual care). All participants had the same number of visits with the in-house Dietitian and free access to the onsite gym. Participants in the control group also received regular grocery vouchers to purchase the foods encouraged by healthy eating guidelines. Recruitment began in February, 2022. After the initial three month study period, DiRECT participants reported consuming 3.0MJ (95% CI 1.2 to 4.8MJ) less energy per day than those in usual care. Mean weight loss was 6kg (2.3-9.6kg) greater for DiRECT participants than usual care participants, while medication use and systolic blood pressure (12mmHg (0-24mmHg)) were lower. Continuous glucose monitoring identified that at baseline, participants on average only spent 10% of the day with a blood glucose reading under 8mmol/L (normoglycaemia). After three months, the usual care group spent on average 48% of the day within the normoglycaemic range, while DiRECT participants spent 78% of the day within the normoglycaemic range. Results at 12 months will enable comment on longer term markers of blood glucose control (HbA1c) and diabetes remission rates, as well as indicate if the body weight, medication, and blood pressure improvements observed at three months are sustained.