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Decreasing population sodium intake has been identified as a "best buy" for reducing non-communicable disease. The aim of this study was to explore 10-year changes in the sodium content of New Zealand processed foods. Nutrient data for nine key food groups were collected in supermarkets in 2003 (n = 323) and 2013 (n = 885). Mean (SD) and median (min, max) sodium content were calculated by food group, year and label type (private/branded). Paired t-tests explored changes in sodium content for all products available for sale in both years (matched; n = 182). The mean (SD) sodium content of all foods was 436 (263) mg (100 g)(-1) in 2003 and 433 (304) mg (100 g)(-1) in 2013, with no significant difference in matched products over time (mean (SD) difference, -56 (122) mg (100 g)(-1), 12%; p = 0.22). The largest percentage reductions in sodium (for matched products) were observed for Breakfast Cereals (28%; -123 (125) mg (100 g)(-1)), Canned Spaghetti (15%; -76 (111) mg (100 g)(-1)) and Bread (14%; -68 (69) mg (100 g)(-1)). The reduction in sodium was greater for matched private vs. branded foods (-69 vs. -50 mg (100 g)(-1), both p < 0.001). There has been modest progress with sodium reduction in some New Zealand food categories over the past 10 years. A renewed focus across the whole food supply is needed if New Zealand is to meet its global commitment to reducing population sodium intake.

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This paper reports on a complex environmental approach to addressing 'wicked' health promotion problems devised to inform policy for enhancing food security and physical activity among Maori, Pacific and low-income people in New Zealand. This multi-phase research utilized literature reviews, focus groups, stakeholder workshops and key informant interviews. Participants included members of affected communities, policy-makers and academics. Results suggest that food security and physical activity 'emerge' from complex systems. Key areas for intervention include availability of money within households; the cost of food; improvements in urban design and culturally specific physical activity programmes. Seventeen prioritized intervention areas were explored in-depth and recommendations for action identified. These include healthy food subsidies, increasing the statutory minimum wage rate and enhancing open space and connectivity in communities. This approach has moved away from seeking individual solutions to complex social problems. In doing so, it has enabled the mapping of the relevant systems and the identification of a range of interventions while taking account of the views of affected communities and the concerns of policy-makers. The complex environmental approach used in this research provides a method to identify how to intervene in complex systems that may be relevant to other 'wicked' health promotion problems.

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BACKGROUND: Free school breakfast programmes (SBPs) exist in a number of high-income countries, but their effects on educational outcomes have rarely been evaluated in randomised controlled trials. METHODS: A 1-year stepped-wedge, cluster randomised controlled trial was undertaken in 14 New Zealand schools in low socioeconomic resource areas. Participants were 424 children, mean age 9±2 years, 53% female. The intervention was a free daily SBP. The primary outcome was children's school attendance. Secondary outcomes were academic achievement, self-reported grades, sense of belonging at school, behaviour, short-term hunger, breakfast habits and food security. RESULTS: There was no statistically significant effect of the breakfast programme on children's school attendance. The odds of children achieving an attendance rate <95% was 0.76 (95% CI 0.56 to 1.02) during the intervention phase and 0.93 (95% CI 0.67 to 1.31) during the control phase, giving an OR of 0.81 (95% CI 0.59 to 1.11), p=0.19. There was a significant decrease in children's self-reported short-term hunger during the intervention phase compared with the control phase, demonstrated by an increase of 8.6 units on the Freddy satiety scale (95% CI 3.4 to 13.7, p=0.001). There were no effects of the intervention on any other outcome. CONCLUSIONS: A free SBP did not have a significant effect on children's school attendance or academic achievement but had significant positive effects on children's short-term satiety ratings. More frequent programme attendance may be required to influence school attendance and academic achievement. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR)-ACTRN12609000854235.

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ISSUE ADDRESSED: Front-of-pack (FOP) labels are identified as a way to encourage healthy food choices and good nutrition, factors critical in promoting health. New Zealand and Australia are currently considering policy on front-of-pack labels. This research aimed to identify the challenges associated with implementing a front-of-pack nutrition labelling policy in New Zealand and with designing research to determine its likely effect. METHODS: A strategic sample of key stakeholders with knowledge of food labelling from New Zealand and Australia participated in the research. The 17 participants included five food industry representatives, six policy makers, and six representatives of non-governmental organisations. RESULTS: Several key themes emerged including support for front-of-pack labels from key food industry, policy and NGO stakeholders because of potential for better informed consumers, changes in consumer behaviour and reduction in chronic disease. Barriers to front-of-pack labelling included limited evidence upon which to make decisions, lack of agreement on the label format, and the clash of values between 'profit driven' industry and public health. There is a high level of agreement about the need for real-life research on the effectiveness of FOP labelling. CONCLUSIONS: The introduction of consistent, comprehensive front-of-pack nutrition labelling in New Zealand has the potential to assist in the effort to promote healthy eating. This research suggests agreement on front-of-pack labels may not be easy to achieve.

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AIMS: Food insecurity is a lack of assured access to sufficient nutritious food. We aimed to investigate the demographic and socio-economic determinants of food insecurity in New Zealand and whether these determinants vary between males and females. METHODS: We used data from the longitudinal Survey of Families, Income and Employment (SoFIE) (n=18,950). Respondents were classified as food insecure if, in the past 12 months, they had to use special food grants or food banks, been forced to buy cheaper food to pay for other things, or had to go without fresh fruit and vegetables often. Logistic regression analyses were used to investigate the association of demographic and socio-economic factors on food insecurity. Models were repeated stratifying by males and females. RESULTS: More than 15% of the SoFIE population in NZ were food insecure in 2004/05. The prevalence of food insecurity was much greater in females (19%) than males (12%). The adjusted odds of food insecurity was significantly higher in females compared to males (OR 1.6, 95% CI 1.5-1.8). In univariate analyses, food insecurity was associated with sole parenthood, unmarried status, younger age groups, Maori and Pacific ethnicity, worse self-rated health status, renting, being unemployed and lower socioeconomic status. Income was the strongest predictor of food insecurity in multivariate modelling (OR 4.9, 95%CI 4.0-5.9 for lowest household income quintile versus highest). The associations of demographic and socioeconomic factors with food insecurity were similar in males and females. CONCLUSIONS: Food insecurity is a timely and relevant issue, as it affects a significant number of New Zealanders. Targeted policy interventions aimed at increasing money available in households are needed.

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BACKGROUND: Approximately 55,000 children in New Zealand do not eat breakfast on any given day. Regular breakfast skipping has been associated with poor diets, higher body mass index, and adverse effects on children's behaviour and academic performance. Research suggests that regular breakfast consumption can improve academic performance, nutrition and behaviour. This paper describes the protocol for a stepped wedge cluster randomised trial of a free school breakfast programme. The aim of the trial is to determine the effects of the breakfast intervention on school attendance, achievement, psychosocial function, dietary habits and food security. METHODS/DESIGN: Sixteen primary schools in the North Island of New Zealand will be randomised in a sequential stepped wedge design to a free before-school breakfast programme consisting of non-sugar coated breakfast cereal, milk products, and/or toast and spreads. Four hundred children aged 5-13 years (approximately 25 per school) will be recruited. Data collection will be undertaken once each school term over the 2010 school year (February to December). The primary trial outcome is school attendance, defined as the proportion of students achieving an attendance rate of 95% or higher. Secondary outcomes are academic achievement (literacy, numeracy, self-reported grades), sense of belonging at school, psychosocial function, dietary habits, and food security. A concurrent process evaluation seeks information on parents', schools' and providers' perspectives of the breakfast programme. DISCUSSION: This randomised controlled trial will provide robust evidence of the effects of a school breakfast programme on students' attendance, achievement and nutrition. Furthermore the study provides an excellent example of the feasibility and value of the stepped wedge trial design in evaluating pragmatic public health intervention programmes. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12609000854235.

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OBJECTIVE: To determine how various population groups in New Zealand interpret the nutrition content claims '97% fat free' and 'no added sugar' on food labels. METHODS: A survey of adult supermarket shoppers was conducted at 25 Auckland supermarkets over a six-week period in 2007. Supermarkets were located in areas where greater than 10% of the resident population were known to be Maori, Pacific or Asian, based on 2001 Census meshblock data. Four questions in the survey assessed understanding and interpretation of the nutrition content claims '97% fat free' and 'no added sugar'. RESULTS: There were 1,525 people who completed the survey, with approximately equal representation from Maori, Pacific, Asian and New Zealand European and Other ethnicities. Nearly three-quarters (72%) of participants correctly estimated the fat content of a 100 g product that was '97% fat free', and understood that a product with 'no added sugars' could contain natural sugar. However, up to three-quarters of Maori, Pacific, and Asian shoppers assumed that if a food carried a '97% fat free' or 'no added sugar' claim it was therefore a healthy food. Similarly, low-income shoppers were significantly more likely than medium- or high-income shoppers to assume that the presence of a claim meant a food was definitely healthy. CONCLUSION: Percentage fat free and no added sugar nutrition content claims on food are frequently misinterpreted by shoppers as meaning the food is healthy overall and appear to be particularly misleading for Maori, Pacific, Asian and low-income groups. IMPLICATIONS: Nutrition content claims have potential for harm if the food they are placed on is not healthy overall. Such claims should therefore only be permitted to be placed on healthy foods.

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AIM: To determine whether a modified version of the Heart Foundation Tick (MHFT) nutrient profiling model appropriately classifies supermarket foods to endorse its use for identifying 'healthier' products eligible for promotion in a supermarket intervention trial. METHODS: Top-selling products (n=550) were selected from an existing supermarket nutrient composition database. Percentage of products classified as 'healthier' by the MHFT and a modified comparator model (Food Standards Australia New Zealand; MFSANZ) were calculated. Percentage agreement, consistency (kappa statistic), and average nutrient values were assessed overall, and across seven food groups. RESULTS: The MHFT model categorised 16% fewer products as 'healthier' than the MFSANZ model. Agreement and consistency between models were 72% and kappa=0.46 (P=0.00), respectively. For both models, 'healthier' products were on average lower in energy, protein, saturated fat, sugar, and sodium than their 'less healthy' counterparts. CONCLUSION: The MHFT nutrient profiling model categorised regularly purchased supermarket foods similarly to the MFSANZ model, and both appear to distinguish appropriately between 'healthier' and 'less healthy' options. Therefore, both models have the potential to appropriately identify 'healthier' foods for promotion and positively influence food choices.

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AIM: To develop healthier vending guidelines and assess their effect on the nutrient content and sales of snack products sold through hospital vending machines, and on staff satisfaction. METHODS: Nutrition guidelines for healthier vending machine products were developed and implemented in 14 snack vending machines at two hospital sites in Auckland, New Zealand. The guidelines comprised threshold criteria for energy, saturated fat, sugar, and sodium content of vended foods. Sales data were collected prior to introduction of the guidelines (March-May 2007), and again post-introduction (March-May 2008). A food composition database was used to assess impact of the intervention on nutrient content of purchases. A staff survey was also conducted pre- and post-intervention to assess acceptability. RESULTS: Pre-intervention, 16% of staff used vending machines once a week or more, with little change post-intervention (15%). The guidelines resulted in a substantial reduction in the amount of energy (-24%), total fat (-32%), saturated fat (-41%), and total sugars (-30%) per 100 g product sold. Sales volumes were not affected, and the proportion of staff satisfied with vending machine products increased. CONCLUSIONS: Implementation of nutrition guidelines in hospital vending machines led to substantial improvements in nutrient content of vending products sold. Wider implementation of these guidelines is recommended.

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Food security is a fundamental human right yet many people are food insecure, even in high-income countries. Reviewed here is the evidence for the physical, economic, sociocultural, and political environmental influences on household food security in high-income countries. The literature was evaluated using the ANGELO framework, which is a lens developed for understanding the environmental factors underpinning the obesity pandemic. A review of the literature identified 78 articles, which mostly reported on cross-sectional or qualitative studies. These studies identified a wide range of factors associated with food security. Foremost among them was household financial resources, but many other factors were identified and the complexity of the issue was highlighted. Few studies were prospective and even fewer tested the use of interventions other than the supplemental nutrition assistance program to address food security. This indicates a solution-oriented research paradigm is required to identify effective interventions and policies to enhance food security. In addition, comprehensive top-down and bottom-up interventions at the community and national levels are urgently needed.

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OBJECTIVE: Effective nutrition labels are part of a supportive environment that encourages healthier food choices. The present study examined the use, understanding and preferences regarding nutrition labels among ethnically diverse shoppers in New Zealand. DESIGN AND SETTING: A survey was carried out at twenty-five supermarkets in Auckland, New Zealand, between February and April 2007. Recruitment was stratified by ethnicity. Questions assessed nutrition label use, understanding of the mandatory Nutrition Information Panel (NIP), and preference for and understanding of four nutrition label formats: multiple traffic light (MTL), simple traffic light (STL), NIP and percentage of daily intake (%DI). SUBJECTS: In total 1525 shoppers completed the survey: 401 Maori, 347 Pacific, 372 Asian and 395 New Zealand European and Other ethnicities (ten did not state ethnicity). RESULTS: Reported use of nutrition labels (always, regularly, sometimes) ranged from 66% to 87% by ethnicity. There was little difference in ability to obtain information from the NIP according to ethnicity or income. However, there were marked ethnic differences in ability to use the NIP to determine if a food was healthy, with lesser differences by income. Of the four label formats tested, STL and MTL labels were best understood across all ethnic and income groups, and MTL labels were most frequently preferred. CONCLUSIONS: There are clear ethnic and income disparities in ability to use the current mandatory food labels in New Zealand (NIP) to determine if foods are healthy. Conversely, MTL and STL label formats demonstrated high levels of understanding and acceptance across ethnic and income groups.

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OBJECTIVE: To determine how well consumers use and understand nutrition labels and claims in New Zealand and Australia. METHOD: A review was undertaken of the literature on nutrition labelling in New Zealand and Australia published up to the end of July 2005. Major electronic databases were searched for appropriate literature and research, as were the bibliographies of relevant publications and pertinent websites. Studies that focused on health claims were excluded. RESULTS: Sixteen papers were suitable for inclusion in the review. All but one study evaluated self-reported use and understanding of nutrition labels. The single study that evaluated actual (observed) use of labels while shopping found frequency to be much lower than would be expected based on self-reported data. While self-reported understanding of nutrition labels was common, actual (evaluated) understanding appeared moderate at best. CONCLUSIONS: Self-reported use of nutrition labels and claims is common in New Zealand and Australia, but actual use and understanding appears limited. Nutrition labels present an opportunity to improve consumer food choice at point of purchase, but their potential value is limited by apparent lack of consumer understanding. IMPLICATIONS: Nutrition labels are an important part of a supportive environment that empowers people to make healthy food choices. Improving their ease of use and understanding has the potential to promote healthier food choices.

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