Protocol for the implementation and evaluation of a community-based intervention seeking to reduce dietary salt intake in Lithgow, Australia

Excess dietary salt is a leading risk for health. Multiple health, government, industry and community organisations have identified the need to reduce consumption of dietary salt. This project seeks to implement and evaluate a community-based salt reduction intervention

Cost-effectiveness of product reformulation in response to the Health Star Rating food labelling system in Australia

The Health Star Rating (HSR) system is a voluntary front-of-pack labelling (FoPL) initiative endorsed by the Australian government in 2014. This study examines the impact of the HSR system on pre-packaged food reformulation measured by changes in energy density between products with and without HSR. The cost-effectiveness of the HSR system was modelled using a proportional multi-state life table Markov model for the 2010 Australian population. We evaluated scenarios in which the HSR system was implemented on a voluntary and mandatory basis (i.e., HSR uptake across 6.7% and 100% of applicable products, respectively). The main outcomes were health-adjusted life years (HALYs), net costs, and incremental cost-effectiveness ratios (ICERs). These were calculated with accompanying 95% uncertainty intervals (95% UI). The model predicted that HSR-attributable reformulation leads to small reductions in mean population energy intake (voluntary: 0.98 kJ/day [95% UI: -1.08 to 2.86]; mandatory: 11.81 kJ/day [95% UI: -11.24 to 36.13]). These are likely to result in reductions in mean body weight (voluntary: 0.01 kg [95% UI: -0.01 to 0.03]; mandatory: 0.11 kg [95% UI: -0.12 to 0.32], and HALYs (voluntary: 4207 HALYs [95% UI: 2438 to 6081]; mandatory: 49,949 HALYs [95% UI: 29,291 to 72,153]). The HSR system evaluated via changes in reformulation could be considered cost-effective relative to a willingness-to-pay threshold of A$50,000 per HALY (voluntary: A$1728 per HALY [95% UI: dominant to 10,445] and mandatory: A$4752 per HALY [95% UI: dominant to 16,236])

Modelled cost-effectiveness of a package size cap and a kilojoule reduction intervention to reduce energy intake from sugar-sweetened beverages in Australia

Interventions targeting portion size and energy density of food and beverage products have been identified as a promising approach for obesity prevention. This study modelled the potential cost-effectiveness of: a package size cap on single-serve sugar sweetened beverages (SSBs) >375 mL ( package size cap ), and product reformulation to reduce energy content of packaged SSBs ( energy reduction ). The cost-effectiveness of each intervention was modelled for the 2010 Australia population using a multi-state life table Markov model with a lifetime time horizon. Long-term health outcomes were modelled from calculated changes in body mass index to their impact on Health-Adjusted Life Years (HALYs). Intervention costs were estimated from a limited societal perspective. Cost and health outcomes were discounted at 3%. Total intervention costs estimated in AUD 2010 were AUD 210 million. Both interventions resulted in reduced mean body weight ( package size cap : 0.12 kg; energy reduction : 0.23 kg); and HALYs gained ( package size cap : 73,883; energy reduction : 144,621). Cost offsets were estimated at AUD 750.8 million ( package size cap ) and AUD 1.4 billion ( energy reduction ). Cost-effectiveness analyses showed that both interventions were "dominant", and likely to result in long term cost savings and health benefits. A package size cap and kJ reduction of SSBs are likely to offer excellent "value for money" as obesity prevention measures in Australia

The sugar and energy in non-carbonated sugar-sweetened beverages: a cross-sectional study.

BACKGROUND: The consumption of non-carbonated sugar-sweetened beverages (NCSSBs) has many adverse health effects. However, the sugar and energy content in NCSSBs sold in China remain unknown. We aimed to investigate the sugar and energy content of NCSSBs in China and how these contents were labelled. METHODS: A cross-sectional survey was conducted in 15 supermarkets in Haidian District, Beijing from July to October 2017. The product packaging and nutrient information panels of NCSSBs were recorded to obtain type of products (local/imported), serving size, nutrient contents of carbohydrate, sugar and energy. For those NCSSBs without sugar content information, we used carbohydrate content as a replacement. RESULTS: A total of 463 NCSSBs met the inclusion criteria and were included in our analysis. The median of sugar content and energy content was 9.6 [interquartile range (IQR): 7.1-11.3] g/100 ml and 176 (IQR: 121-201) kJ/100 ml. The median of sugar contents in juice drinks, tea-based beverages, sports drinks and energy drinks were 10.4, 8.5, 5.0 and 7.4 g/100 ml. Imported products had higher sugar and energy content than local products. There were 95.2% products of NCSSBs receiving a 'red'(high) label for sugars per portion according to the UK criteria, and 81.6% products exceeding the daily free sugar intake recommendation from the World Health Organization (25 g). There were 82 (17.7%) products with sugar content on the nutrition labels and 60.2% of them were imported products. CONCLUSIONS: NCSSBs had high sugar and energy content, and few of them provided sugar content information on their nutrition labels especially in local products. Measures including developing better regulation of labelling, reducing sugar content and restricting the serving size are needed for reducing sugar intakes in China

Reliable quantification of the potential for equations based on spot urine samples to estimate population salt intake: protocol for a systematic review and meta-analysis

Background: Methods based on spot urine samples (a single sample at one time-point) have been identified as a possiblealternative approach to 24-hour urine samples for determining mean population salt intake.Objective: The aim of this study is to identify a reliable method for estimating mean population salt intake from spot urinesamples. This will be done by comparing the performance of existing equations against one other and against estimates derivedfrom 24-hour urine samples. The effects of factors such as ethnicity, sex, age, body mass index, antihypertensive drug use, healthstatus, and timing of spot urine collection will be explored. The capacity of spot urine samples to measure change in salt intakeover time will also be determined. Finally, we aim to develop a novel equation (or equations) that performs better than existingequations to estimate mean population salt intake.Methods: A systematic review and meta-analysis of individual participant data will be conducted. A search has been conductedto identify human studies that report salt (or sodium) excretion based upon 24-hour urine samples and spot urine samples. Therewere no restrictions on language, study sample size, or characteristics of the study population. MEDLINE via OvidSP (1946-present),Premedline via OvidSP, EMBASE, Global Health via OvidSP (1910-present), and the Cochrane Library were searched, and tworeviewers identified eligible studies. The authors of these studies will be invited to contribute data according to a standard format.Individual participant records will be compiled and a series of analyses will be completed to: (1) compare existing equations forestimating 24-hour salt intake from spot urine samples with 24-hour urine samples, and assess the degree of bias according tokey demographic and clinical characteristics; (2) assess the reliability of using spot urine samples to measure population changesin salt intake overtime; and (3) develop a novel equation that performs better than existing equations to estimate mean populationsalt intake.Results: The search strategy identified 538 records; 100 records were obtained for review in full text and 73 have been confirmedas eligible. In addition, 68 abstracts were identified, some of which may contain data eligible for inclusion. Individual participantdata will be requested from the authors of eligible studies.Conclusions: Many equations for estimating salt intake from spot urine samples have been developed and validated, althoughmost have been studied in very specific settings. This meta-analysis of individual participant data will enable a much broaderunderstanding of the capacity for spot urine samples to estimate population salt intake

Food environment interventions to address obesity and related non-communicable diseases in Australia

In less than 30 years the prevalence of overweight and obesity has nearly doubled worldwide. Unhealthy food environments encourage unhealthy diets and energy overconsumption, which is a prevailing driver of unhealthy weight gain, and are seen as an important contributor to the obesity epidemic. This thesis aimed to identify potential public health actions to improve the nutritional composition of the Australian packaged food environment in an effort to address obesity and related non-communicable diseases (NCDs). The research comprises of three components: (i) a review of the existing evidence on the contributions of the food supply to obesity and related-NCDs, including a cross-sectional analysis of the Australian packaged food supply; (ii) a cross-sectional analysis on currently implemented food environment interventions to address obesity and NCDs; (iii) a modelled assessment on the potential health impacts and cost-benefits of implementing selected food environment interventions in Australia. Analyses of the Australian packaged food environment found that the proportion of foods defined as discretionary was 53.0% and proportion of foods defined as highly processed was 60.5%. Population-wide food supply interventions addressing sodium and trans fat reduction have proven highly effective and comparable efforts are now required to target obesity. The evidence suggests that strategies focusing upon reducing the energy density and portion size of foods will be more effective than those targeting specific macronutrients. Specifically, cost-effectiveness analyses of a portion size cap and energy reduction of sugar-sweetened beverages were ‘dominant’, and likely to offer excellent ‘value for money’ as obesity prevention measures in Australia. Governments around the world have recognised the need to implement public health policies and initiatives to curb the epidemic at hand. The nutritional composition of the food environment is one such area where action is needed. Globally there is a strong need for a governance framework which monitors and reports on the implementation and impact of such initiatives to determine what is working, and to hold key stakeholders such as the food industry accountable for their contribution or lack thereof

Know Your Noodles! Assessing Variations in Sodium Content of Instant Noodles across Countries

Reducing salt intake is a cost-effective public health intervention to reduce the global burden of non-communicable disease (NCDs). Ultra-processed foods contribute ~80% of dietary salt in high income countries, and are becoming prominent in low-middle income countries. Instant noodle consumption is particularly high in the Asia Pacific region. The aim of this study was to compare the sodium content of instant noodles sold worldwide to identify potential for reformulation. Analysis was undertaken for 765 instant noodle products from 10 countries using packaged food composition databases of ultra-processed foods compiled by the Global Food Monitoring Group (GFMG) and national shop survey data. Sodium levels were high and variable, within and between countries. Instant noodles in China had the highest mean sodium content (1944 mg/100 g, range: 397-3678/100 g) compared to New Zealand (798 mg/100 g, range: 249-2380 mg/100 g). Average pack size ranged from 57 g (Costa Rica) to 98 g (China). The average packet contributed 35% to 95% of the World Health Organization recommended daily salt intake of (PICs) regional sodium targets, 37% met the South Africa 2016 targets, and 62% met the UK 2017 targets. This study emphasises a need for stronger regulation and closer monitoring to drive rigorous reformulation of salt in ultra-processed foods