Associate Professor Leanne Brown

Objectives This study sought first to empirically define dietary patterns and to apply the novel Dietary Inflammation Score (DIS) in data from rural and metropolitan populations in Australia, and second to investigate associations with cardiovascular disease (CVD) risk factors. Design Cross-sectional study. Setting Rural and metropolitan Australia. Participants Adults over the age of 18 years living in rural or metropolitan Australia who participated in the Australian Health survey. Primary outcomes A posteriori dietary patterns for participants separated into rural and metropolitan populations using principal component analysis. Secondary outcomes: association of each dietary pattern and DIS with CVD risk factors was explored using logistic regression. Results The sample included 713 rural and 1185 metropolitan participants. The rural sample was significantly older (mean age 52.7 compared with 48.6 years) and had a higher prevalence of CVD risk factors. Two primary dietary patterns were derived from each population (four in total), and dietary patterns were different between the rural and metropolitan areas. None of the identified patterns were associated with CVD risk factors in metropolitan or rural areas, aside diet pattern 2 being strongly associated with from self-reported ischaemic heart disease (OR 13.90 95% CI 2.29 to 84.3) in rural areas. There were no significant differences between the DIS and CVD risk factors across the two populations, except for a higher DIS being associated with overweight/obesity in rural areas. Conclusion Exploration of dietary patterns between rural and metropolitan Australia shows differences between the two populations, possibly reflective of distinct cultures, socioeconomic factors, geography, food access and/or food environments in the different areas. Our study provides evidence that action targeting healthier dietary intakes needs to be tailored to rurality in the Australian context.

Objectives To explore and synthesise the evidence relating to features of quality in rural health student placements. Design Scoping review. Data sources MEDLINE, CINAHL, Embase, ProQuest, Informit, Scopus, ERIC and several grey literature data sources (1 January 2005 to 13 October 2020). Study selection The review included peer-reviewed and grey literature from Organisation for Economic Co-operation and Development listed countries that focused on quality of health student placements in regional, rural and remote areas. Data extraction Data were extracted regarding the methodological and design characteristics of each data source, and the features suggested to contribute to student placement quality under five categories based on a work-integrated learning framework. Results Of 2866 resulting papers, 101 were included for data charting and content analysis. The literature was dominated by medicine and nursing student placement research. No literature explicitly defined quality in rural health student placements, although proxy indicators for quality such as satisfaction, positive experiences, overall effectiveness and perceived value were identified. Content analysis resulted in four overarching domains pertaining to features of rural health student placement quality: (1) learning and teaching in a rural context, (2) rural student placement characteristics, (3) key relationships and (4) required infrastructure. Conclusion The findings suggest that quality in rural health student placements hinges on contextually specific features. Further research is required to explore these findings and ways in which these features can be measured during rural health student placements.

Objective: Combined, nursing and allied health constitute most of the Australian health workforce; yet, little is known about graduate practice destinations. University Departments of Rural Health have collaborated on the Nursing and Allied Health Graduate Outcomes Tracking to investigate graduate entry into rural practice. Design: Data linkage cohort study. Setting: Monash University and the University of Newcastle. Participants: Graduates who completed their degree in 2017 across seven disciplines. Main outcome measure(s): The outcome variable was Australian Health Practitioner Regulation Agency principal place of practice data. Explanatory variables included discipline, age, gender, location of origin, and number and duration of rural placements. Result: Of 1130 graduates, 51% were nurses, 81% females, 62% under 21¿years at enrolment, 23% of rural origin, 62% had at least one rural student placement, and 23% had over 40 cumulative rural placement days. At the time of their second Australian Health Practitioner Regulation Agency registration, 18% worked in a ¿Rural principal place of practice.¿ Compared to urban, rural origin graduates had 4.45 times higher odds ratio of ¿Rural principal place of practice.¿ For graduates who had <20 cumulative rural placement days, compared to zero the odds ratio of ¿Rural principal place of practice¿ was the same (odds ratio¿=¿1.10). For those who had 20-40 rural placement days, the odds ratio was 1.93, and for >40 rural placement days, the odds ratio was 4.54). Conclusion: Rural origin and more rural placement days positively influenced graduate rural practice destinations. Outcomes of cumulative placements days may compare to immersive placements.

Objective: Linking enrolment and professional placement data for students' from 2 universities, this study compares characteristics across universities and health disciplines. The study explores associations between students' location of origin and frequency, duration and type of placements. Design: Retrospective cohort data linkage. Setting: Two Australian universities, Monash University and the University of Newcastle. Participants: Students who completed medical radiation science, nursing, occupational therapy, pharmacy or physiotherapy at either university between 2 February 2017 and 28 February 2018. Interventions: Location of origin, university and discipline of enrolment. Main outcome measure(s): Main measures were whether graduates had multiple rural placements, number of rural placements and cumulative rural placement days. Location of origin, discipline and university of enrolment were the main explanatory variables. Secondary dependent variables were age, sex, socio-economic indices for location of origin, and available placements. Results: A total of 1,315 students were included, of which 22.1% were of rural origin. The odds of rural origin students undertaking a rural placement was more than 4.5 times greater than for urban origin students. A higher proportion of rural origin students had multiple rural placement (56.0% vs 14.9%), with a higher mean number of rural placement days. Public hospitals were the most common placement type, with fewer in primary care, mental health or aged care. Conclusions: There is a positive association between rural origin and rural placements in nursing and allied health. To help strengthen recruitment and retention of graduates this association could be further exploited, while being inclusive of non-rural students.

Introduction: Innovative eHealth solutions that improve access to child weight management interventions are crucial to address the rising prevalence of childhood obesity globally. The study aimed to evaluate the feasibility and preliminary efficacy of a 12-week online telehealth nutrition intervention to improve child weight and dietary outcomes, and the impact of additional text messages (SMS) targeted to mothers and fathers. Methods: Families with children aged 4 to 11 were randomised across three groups: Telehealth, Telehealth+SMS, or Waitlist control. Telehealth and Telehealth+SMS groups received two telehealth consultations delivered by a dietitian, 12 weeks access to a nutrition website and a private Facebook group. The Telehealth+SMS group received additional SMS. Feasibility was assessed through recruitment, retention, and intervention utilisation. Efficacy was assessed through changes in measured child body mass index (BMI), waist circumference and diet. Results: Forty-four (96%) and 36 (78%) families attended initial and second telehealth consultations, respectively. Thirty-six families (78%) completed week 12 assessments. Child BMI and waist circumference changes from baseline to week 12 were not statistically different within or between groups. Children in Telehealth+SMS had significantly reduced percentage energy from energy-dense nutrient-poor food (95% CI -21.99 to -0.03%E; p =.038) and increased percentage energy from healthy core food (95% CI -0.21 to 21.89%E; p =.045) compared to Waitlist control. Discussion: A family-focused online telehealth nutrition intervention is feasible. While the modest sample size reduced power to detect between-group changes in weight status, some improvements in child dietary intakes were identified in those receiving telehealth and SMS.

Introduction: Previous reviews of family-based interventions for childhood obesity treatment found that studies were of low methodological quality with inadequate details reported, especially related to intervention fidelity. The evaluation of fidelity is crucial to inform interpretation of the intervention outcomes. This study aimed to summarise intervention fidelity, participants¿ acceptability and satisfaction with a 12-week family-focused technology-based child nutrition and weight management intervention. Methods: Families with children aged 4¿11 years participated in a telehealth intervention with complementary components: website, Facebook group and text messages. Intervention fidelity was reported using National Institutes of Health Treatment Fidelity Framework. Delivery was measured using a dietitian-reported evaluation survey. Google Analytics and Bitly platform were used to objectively track data on frequency and pattern of intervention use. Participants¿ acceptability and satisfaction were measured using a process evaluation survey. Results: Telehealth consultations delivered by trained dietitians had good adherence (=83%) to the structured content. Process evaluation results indicated that parents (n = 30; mean age 41 years, 97% were female, body mass index 30 kg/m2) found the intervention components easy to use/understand (87¿100%), the programme had improved their family/child eating habits (93%), and they wanted to continue using telehealth and the website, as well as recommending it to other parents (90¿91%). Discussion: In summary, a family-focused technology-based child nutrition and weight management intervention using telehealth, website, Facebook and SMS can be delivered by trained dietitians with good fidelity and attain high acceptability and satisfaction among families with primary-school-aged children in New South Wales, Australia.

Background: Dietary intake is an important modifiable risk factor for cardiovascular disease. However, to our knowledge, there are no systematic reviews of nutrition interventions in the context of cardiovascular disease prevention and management within rural communities. This is important to investigate, given the unique geographic, social, and contextual factors associated with rurality. Objective: Our primary objective was to systematically assess evidence on the effectiveness of randomized controlled trials to improve dietary intake in the context of cardiovascular disease prevention and management in rural communities. Methods: Nine electronic databases were searched from inception to June 2020, including MEDLINE, The Cochrane Library, Embase, Emcare, PsycINFO, Scopus, Rural and Remote Health, CINAHL, and AMED. Randomized controlled trials that reported results of interventions with adult, rural populations and measured change in dietary intake compared to usual care, alternative intervention, or no intervention controls were included. Included randomized controlled trials were also assessed according to the TIDieR (Template for Intervention Description and Reporting) checklist and RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. Results: Thirteen articles reporting results of randomized controlled trials were identified. Included articles reported a range of nutrition interventions and measured 18 dietary intake outcomes. Most studies (n = 10) demonstrated effectiveness in altering at least 1 dietary intake outcome, including fruit and/or vegetable (n = 9), fiber (n = 2), Dietary Risk Assessment score (n = 2), energy, dairy, carotene, vitamin C and sodium (all n = 1). However, there was wide variation in the reporting of intervention components (according to the TIDieR checklist) and impact (according to RE-AIM framework), resulting in difficulty interpreting the ¿real-world¿ implications of these results. Conclusions: Through this systematic review, we found limited evidence of improvement in dietary intakes due to nutrition interventions in the context of cardiovascular disease prevention and management in rural communities. Fruit and/or vegetable intakes were the most frequently reported dietary intake outcomes, and most likely to be improved across the included studies. Included studies were generally not well reported, which may hinder replication by clinicians and consolidation of the evidence base by other researchers. Given the substantial burden of cardiovascular disease experienced by those living in rural areas of developed countries, additional high-quality nutrition research that acknowledges the complexities of rural health is required.

Introduction: A lack of core food accessibility negatively affects diet quality, potentially increasing the prevalence of health risk factors such as obesity. The purpose of this study was to investigate core food access in an Australian regional center through the use of data visualization techniques. Methods: Supermarkets were used as a proxy for core food accessibility and were identified and mapped by town region with a combination of Google Maps and Stata/IC 15.1 software. A statistical analysis comparing the demographics of each town region was also completed using Stata. Results: The maps generated suggest that there may be a disparity in core food accessibility between town regions. The analysis of demographics demonstrated that one town region had a greater proportion of disadvantaged residents, with statistically significant variation between regions. Conclusion: Data visualization and analysis may be a useful tool for clinicians to communicate accessibility information experienced by local residents. This need not be limited to food accessibility and extended to health services.

Introduction: An optimal diet is imperative in preparing women for pregnancy and this may be influenced by socio-economic status (SES). This research aims to investigate the role of SES on the dietary energy density (ED) in Australian women of preconception age. Methods: A secondary analysis of the Australian National Nutrition and Physical Activity Survey 2011¿12 for females aged 18¿39¿years (n¿=¿1617) was conducted. Dietary intake was assessed by 24-hr recalls and dietary ED by dietary energy per weight (kJ.g-1). ED was further categorised as ED of foods and beverages separately. SES was assessed by three variables: Socio-Economic Indexes for Areas (SEIFA), developed by the Australian Bureau of Statistics; income decile; and level of education. Linear mixed model regressions were used to identify associations between ED and SES. Results: The median ED for food, beverages and combined food and beverages was 9.38¿kJ g-1, 1.02 kJ g-1 and 7.11¿kJ g-1, respectively. No significant variation was explained by SES variables when analysing combined ED in the adjusted model or ED from foods. Income decile reduced ED of beverages, although with little effect (coefficient: -0.04, P¿=¿0.002). Significant confounders included inactivity, which increased ED in both combined ED and ED foods (coefficient: 0.51, P¿=¿0.001 and coefficient: 0.78, P¿<¿0.001). Conclusions: SES explained little variation in dietary ED in women of childbearing age. A large proportion of women had high energy-dense diets regardless of their SES. These findings suggest that a large proportion of women, who may become pregnant, have diets that exceed the international recommendations for dietary energy density.

Aim: The aim was to support rich collaborative practice between two professions who frequently work together across both ordered and organic modes of collaboration. Methods: This study uses a qualitative research approach of collaborative dialogical inquiry to explore the question ¿From the perspective of dietitians and speech pathologists, ¿what works well¿ for developing and maintaining collaborative practice?¿ We deliberately chose a context where collaborative practice is evident, University Department of Rural Health (UONDRH). Participants in the research were academics and clinicians from dietetics and speech pathology. Data were sourced from our research reflections and focus group transcriptions. Analysis was dialogical and iterative. Results: Beyond shared purpose, knowledge of roles and good communication, the notions of curiosity, willingness and momentum were at the core of ¿what works well¿ for collaborative practice between dietitians and speech pathologists. Participant perspectives related to collaborative practice between these professions and beyond to other professions, and involved collaborative practice within and across healthcare organisations and a university setting. Conclusions: Our interpreted themes of curiosity, willingness and momentum for developing and maintaining collaborative practice highlight the importance of paying attention to the less visible and difficult to measure aspects of patient-centred care. Questions for reflection are suggested to inform the ongoing process of developing and maintaining our and others¿ collaborative practice.

Objective: To describe and compare body composition and fat distribution of Australian women 18¿44 years from an urban and rural location. Design: Cross-sectional survey and collection of anthropometric and body composition measurements. Setting: Newcastle and Tamworth in New South Wales. Participants: Convenience sample of women recruited through media and community. Main outcome measures: Weight, height, waist and hip girths, visceral fat area, body fat (kg and %) and skeletal muscle mass. Results: Of the total sample (n = 254), 53% resided in an urban area and the mean age was 28.0 (7.6) years. The mean age of rural women was significantly higher than for urban women. The majority of women (66.5%) had a Body Mass Index within the healthy range (18.5¿24.9 kg m -2 ) and there was no significant difference in mean Body Mass Index between rural and urban women. Measures of central fat distribution, waist circumference and waist-to-hip ratio were significantly higher in rural residents. Visceral fat area was significantly higher among rural women. After adjustment for age, differences in waist circumference, waist-to-hip ratio and visceral fat area were no longer statistically significant. Conclusion: While we did not find statistically significant differences in body composition among urban and rural women, these results highlight the dramatic effect of age on measures of central adiposity. Population surveillance needs to incorporate measures of excess central adiposity, particularly visceral fat area, to better investigate changes in body composition among women in their 20s and 30s.

Childhood obesity rates are higher among Indigenous compared with non-Indigenous Australian children. It has been hypothesized that early-life influences beginning with the intrauterine environment predict the development of obesity in the offspring. The aim of this paper was to assess, in 227 mother-child dyads from the Gomeroi gaaynggal cohort, associations between prematurity, Gestation Related-Optimal Weight (GROW) centiles, maternal adiposity (percentage body fat, visceral fat area), maternal non-fasting plasma glucose levels (measured at mean gestational age of 23.1 weeks) and offspring BMI and adiposity (abdominal circumference, subscapular skinfold thickness) in early childhood (mean age 23.4 months). Maternal non-fasting plasma glucose concentrations were positively associated with infant birth weight (P=0.005) and GROW customized birth weight centiles (P=0.008). There was a significant association between maternal percentage body fat (P=0.02) and visceral fat area (P=0.00) with infant body weight in early childhood. Body mass index (BMI) in early childhood was significantly higher in offspring born preterm compared with those born at term (P=0.03). GROW customized birth weight centiles was significantly associated with body weight (P=0.01), BMI (P=0.007) and abdominal circumference (P=0.039) at early childhood. Our findings suggest that being born preterm, large for gestational age or exposed to an obesogenic intrauterine environment and higher maternal non-fasting plasma glucose concentrations are associated with increased obesity risk in early childhood. Future strategies should aim to reduce the prevalence of overweight/obesity in women of child-bearing age and emphasize the importance of optimal glycemia during pregnancy, particularly in Indigenous women.

Issue addressed Undergraduate dietetic students are required to demonstrate cultural awareness and culturally respectful communication to meet national competencies, but exposure to practical experiences may be limited. The Gomeroi gaaynggal ArtsHealth Centre was established in 2009 after community consultation with the Indigenous community in Tamworth, New South Wales. The Centre provides a safe and welcoming space where women can create art while discussing health issues with visiting health professionals and students. The present study aimed to evaluate the cultural experiences of student and new-graduate dietitians visiting an Aboriginal ArtsHealth centre through a quality assurance project. Methods Six student and new-graduate dietitians were invited to provide feedback on their experiences for this report. A generic inductive approach was used for qualitative data analysis. Results Key qualitative themes of 'building rapport' and 'developing cultural understanding' were identified. Four of the participants interviewed felt they gained a deeper understanding of the context around health disparity for Indigenous Australians through their experiences. Key ways to build rapport with community members were identified. Conclusions Results suggest that first-hand experiences working in an Aboriginal ArtsHealth centre are effective in building cultural competency skills for student and new-graduate dietitians. These experiences could be better supported through improved preparation for the cultural setting, and ongoing monitoring of participant experiences is recommended. So what? The authors encourage undergraduate dietetic programs and students to seek out opportunities for further development of cultural awareness through increased practical experiences working with Indigenous communities.

Indigenous Australians have high rates of chronic diseases, the causes of which are complex and include social and environmental determinants. Early experiences in utero may also predispose to later-life disease development. The Gomeroi gaaynggal study was established to explore intrauterine origins of renal disease, diabetes and growth in order to inform the development of health programmes for Indigenous Australian women and children. Pregnant women are recruited from antenatal clinics in Tamworth, Newcastle and Walgett, New South Wales, Australia, by Indigenous research assistants. Measures are collected at three time points in pregnancy and from women and their children at up to eight time points in the child's first 5 years. Measures of fetal renal development and function include ultrasound and biochemical biomarkers. Dietary intake, infant feeding and anthropometric measurements are collected. Standardized procedures and validated tools are used where available. Since 2010 the study has recruited over 230 women, and retained 66 postpartum. Recruitment is ongoing, and Gomeroi gaaynggal is currently the largest Indigenous pregnancy-through-early-childhood cohort internationally. Baseline median gestational age was 39.1 weeks (31.5-43.2, n=110), median birth weight was 3180 g (910-5430 g, n=110). Over one third (39.3%) of infants were admitted to special care or neonatal nursery. Nearly half of mothers (47.5%) reported tobacco smoking during pregnancy. Results of the study will contribute to knowledge about origins of chronic disease in Indigenous Australians and nutrition and growth of women and their offspring during pregnancy and postpartum. Study strengths include employment and capacity-building of Indigenous staff and the complementary ArtsHealth programme.

Objective: To assess the research contribution of eleven University Departments of Rural Health (UDRH) which were established as a rural health workforce program in the late 1990s through analysis of peer-reviewed journal output. Design and settings: Descriptive study based on validated publications from publication output reported in annual key performance indicator (KPI) reports to the Commonwealth Department of Health, Australia. Main outcome measures: In addition to counts and the type of publications, articles were examined to assess fields of research, evidence of research collaboration, and potential for influencing policy. Funding acknowledgement was examined to provide insight into funding sources and research consultancies. Results: Of the 182 peer-reviewed articles, UDRH staff members were the first and corresponding author for 45% (n=82); most (69%, n=126) were original research. Most publications examined included Australian data only (80%, n=101). Over half (56%; n=102) of the articles addressed rural health issues; Aboriginal health was the main subject in 14% (n=26). Thirty-three articles (18%) discussed the policy implications of the research and only half (51%, n=93) of the articles listed sources of funding. Number of authors per article ranged from 1-19, with a mean of 5 (SD=3.2) authors per article, two-thirds of articles included authors from 2-5 universities/organisations but only 5% of articles included an author from more than one UDRH. Conclusions: Staff from UDRHs are regularly publishing peer-reviewed articles, and research productivity demonstrated cooperation with external partners. Better collaboration between UDRH staff and others may help increase the quality and value of Australian rural health research.

Over the past 10 years, the University of Newcastle Department of Rural Health, based in Tamworth, New South Wales, has supported increased opportunities for short- and longterm rural dietetic placements through an ongoing collaboration between Hunter New England Local Health District dietitians and University of Newcastle academic staff, using an innovative student placement model. A recent strategy has been the implementation of year-long student attachments to a rural area in an attempt to improve long-term recruitment and retention of staff to rural and remote areas. This paper describes the dietetic student placement model and outcomes to date. There has been an increase in the number and diversity of student placements in Tamworth, from 2 student placements in 2002 to 33 in 2013 and a maximum increase of 317 student weeks. Students have rated the short- and long-term options highly. Intention to work rurally after graduation was reported at 49% for the 2011/2012 cohort of students. Seventy-three percent of all year-long students have obtained work in a rural setting after graduation. An increased exposure to a rural location has the potential to increase the recruitment of staff in rural areas.

Background: Evidence supports strong associations between healthful eating patterns and maintaining a healthy weight with favourable health outcomes for breast cancer survivors (BCS). The present study aimed to evaluate the diet quality of Australian BCS and to determine whether diet quality differed between BCS and age-matched healthy controls (HC) or by geographical location. Methods: This cross-sectional study included 281 BCS and 4069 HC from the Australian Longitudinal Study on Women's Health mid-aged cohort completing Survey 3 in 2001. Data from the Dietary Questionnaire for Epidemiological Studies food frequency questionnaire were used to calculate the Australian Recommended Food Score (ARFS), a validated summary estimate of diet quality based on adherence to the Australian dietary guidelines. Results: The mean (SD) ARFS of the BCS group was 33.2 (9.4) out of a maximum of 74. Mean (SD) total ARFS and component scores of BCS did not differ from the HC group [32.9 (8.7)] and no differences were found in ARFS between urban and rural BCS. Conclusions: This is the first study dedicated exclusively to describing the diet quality of Australian BCS. Although no difference was found when comparisons were made with a HC group, there is considerable room for improvement in the diet quality of Australian BCS. Given research suggesting higher risk of chronic conditions such as obesity amongst BCS, and the recognition of optimising diet quality as a key factor in health promotion for all population groups, data from the present study suggest the need for research targeting the feasibility and impact of improving diet quality of Australian BCS.