Associate Professor Rachel Sutherland

Colorectal cancer presents via multiple different clinical phenotypes that can arise from a variety of different genetic and molecular alterations. The aim of this study was to describe survival outcomes and treatment patterns of metastatic colorectal cancer (mCRC) patients by v-raf murine sarcoma viral oncogene homolog B1 (BRAF) mutation status. The Alberta Cancer Registry was used to identify all patients >18 years old who had been diagnosed with mCRC in Alberta between 1 January 2017 and 31 December 2019 and had received at least one cycle of systemic therapy. Treatment patterns were compared between wild-type and mutant BRAF mCRC patients. Cox regression models and Kaplan¿Meier curves were created to assess survival differences by both treatment pattern and BRAF status. A total of 488 patients were identified with mCRC, of which 42 (11.4%) were confirmed to have a BRAF mutation. The most common first-line treatment regimen was either capecitabine and oxaliplatin (CAPOX) or leucovorin calcium (folinic acid), fluorouracil, and oxaliplatin (FOLFOX). The median overall survival for mCRC patients was 20.01 months. Mutant BRAF patients had a median survival of 8.21 months compared to 20.03 months among those with wild-type BRAF. BRAF mutations among mCRC patients are associated with a considerably poor prognosis, reinforcing the need for clinical BRAF testing among newly diagnosed patients to better understand their prognosis.

Objectives: Health Promotion Units within New South Wales (NSW) local health districts (LHDs) frequently collaborate and test innovations to address priority health issues or approaches to support the implementation of a health promotion program in a way that is consistent with the needs, resources, and contexts of their regions. Compatible with learning health system approaches, mechanisms to facilitate the exchange of evidence and expertise across districts could improve the collective impact of health promotion services across the state. This study aimed to assess the use of a health promotion Community of Practice (CoP) model as a strategy to achieve this. Type of program or service: This paper describes and shares experiences from the development and piloting process of a CoP model to develop, evaluate and exchange learnings to improve approaches to support the adoption of an effective healthy lunchbox program (¿SWAP IT¿) across three LHDs. Results: The functioning of the CoP was supported by key activities, funding and infrastructure over a 2-year period, including: planning workshops, implementation check-ins, and knowledge exchange meetings. A particularly novel aspect of the CoP was the harmonised evaluation of different, locally developed strategies to facilitate program adoption across the three LHDs. The alignment of the CoP with local and state priorities, as well as the operation of the CoP in a way that did not impose significant time demands, was seen as important for the sustainability of the CoP.

Background & Aims: Despite the widespread increase in the incidence of early-onset colorectal cancer (EoCRC), the reasons for this increase remain unclear. The objective of this study was to determine risk factors for the development of EoCRC. Methods: We conducted a systematic literature review and meta-analysis of studies examining non-genetic risk factors for EoCRC, including demographic factors, comorbidities, and lifestyle factors. Random effects meta-analyses were conducted for risk factors that were examined in at least three studies. Heterogeneity was investigated using the Q-test and I2 statistic. Results: From 3304 initial citations, 20 studies were included in this review. Significant risk factors for EoCRC included CRC history in a first-degree relative (RR 4.21, 95% CI 2.61-6.79), hyperlipidemia (RR 1.62, 95% CI 1.22-2.13), obesity (RR 1.54, 95% CI 1.01-2.35), and alcohol consumption (high vs. non-drinkers) (RR 1.71, 95% CI 1.62-1.80). While smoking was suggestive as a risk factor, the association was not statistically significant (RR 1.35, 95% CI 0.81-2.25). With the exception of alcohol consumption, there was considerable heterogeneity among studies (I2 > 60%). Other potential risk factors included hypertension, metabolic syndrome, ulcerative colitis, chronic kidney disease, dietary factors, sedentary behaviour, and occupational exposure to organic dusts, but these were only examined in one or two studies. Conclusions: The results of this study advance the understanding of the etiology of EoCRC. High-quality studies conducted on generalizable populations and that comprehensively examine risk factors for EoCRC are required to inform primary and secondary prevention strategies.

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy (¿Everyday¿) and less healthy (¿Occasional¿ or ¿Should not be sold¿) items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing ¿Everyday¿ items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing ¿Occasional¿ (OR: 0.86; p = 0.048) and ¿Should not be sold¿ (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

Objectives: Assess the impact of an implementation intervention on student's physical activity, health-related quality of life (HRQoL) and on-task behaviour. Design: A cluster-randomised controlled trial. Methods: Following baseline 61 eligible schools were randomised to a 12-month, implementation intervention to increase teacher scheduling of physical activity, or a waitlist control. Whole school-day and class-time physical activity of students from grades 2 and 3 (~ages 7 to 9) were measured via wrist-worn accelerometers and included: moderate-to-vigorous physical activity, light physical activity, sedentary behaviour and activity counts per minute. Children's health related quality of life (HRQoL) and out-of-school-hours physical activity was measured via parent-proxy surveys. Class level on-task behaviour was measured via teacher self-report surveys. Student and teacher obtained outcomes were measured at baseline and 12-month follow-up. Parent reported outcomes were measured at 12-month follow-up. Linear mixed models compared between group differences in outcomes. Differential effects by sex were explored for student and parent reported outcomes. Results: Data from 2485 students, 1220 parents and >500 teachers were analysed. There was no statistically significant between group differences in any of the outcomes, including accelerometer measured physical activity, out-of-school-hours physical activity, HRQoL, and on-task behaviour. A statistically significant differential effect by sex was found for sedentary behaviour across the whole school day (3.16 min, 95% CI: 0.19, 6.13; p = 0.028), with females illustrating a greater difference between groups than males. Conclusions: Only negligible effects on student physical activity were found. Additional strategies including improving the quality of teacher's delivery of physical activity may be required to enhance effects.

Background: Effectively scaled-up physical activity interventions are urgently needed to address the high prevalence of physical inactivity. To facilitate scale-up of an efficacious school-based physical activity program (Physical Activity 4 Everyone [PA4E1]), provision of implementation support to physical education (PE) teachers was adapted from face-to-face and paper-based delivery modes to partial delivery via a website. A lack of engagement (usage and subjective experience) with digital delivery modes, including websites, may in part explain the typical reduction in effectiveness of scaled-up interventions that use digital delivery modes. A process evaluation focused on the PA4E1 website was undertaken. Objective: The 2 objectives were to (1) describe the usage of the PA4E1 program website by in-school champions (PE teachers leading the program within their schools) and PE teachers using quantitative methods; (2) examine the usage, subjective experience, and usability of the PA4E1 program website from the perspective of in-school champions using mixed methods. Methods: The first objective used website usage data collected across all users (n=273) throughout the 9 school terms of the PA4E1 implementation support. The 4 usage measures were sessions, page views, average session duration, and downloads. Descriptive statistics were calculated and explored across the duration of the 26-month program. The second objective used mixed methods, triangulating data from the first objective with data from a think-aloud survey and usability test completed by in-school champions (n=13) at 12 months. Qualitative data were analyzed thematically alongside descriptive statistics from the quantitative data in a triangulation matrix, generating cross-cutting themes using the "following a thread" approach. Results: For the first objective, in-school champions averaged 48.0 sessions per user, PE teachers 5.8 sessions. PE teacher sessions were of longer duration (10.5 vs 7.6 minutes) and included more page views (5.4 vs 3.4). The results from the mixed methods analysis for the second objective found 9 themes and 2 meta-themes. The first meta-theme indicated that the website was an acceptable and appropriate delivery mode, and usability of the website was high. The second meta-theme found that the website content was acceptable and appropriate, and identified specific suggestions for improvement. Conclusions: Digital health interventions targeting physical activity often experience issues of lack of user engagement. By contrast, the findings from both the quantitative and mixed methods analyses indicate high usage and overall acceptability and appropriateness of the PA4E1 website to school teachers. The findings support the value of the website within a multidelivery mode implementation intervention to support schools to implement physical activity promoting practices. The analysis identified suggested intervention refinements, which may be adopted for future iterations and further scale-up of the PA4E1 program.

Objective: School food intake of Australian children is not comprehensively described in literature, with limited temporal, nationally representative data. Greater understanding of intake at school can inform school-based nutrition promotion. This study aimed to describe the dietary intake of primary-aged children during school hours and its contribution to daily intake. Design: This secondary analysis used nationally representative, cross-sectional data from the 2011 to 2012 National Nutrition and Physical Activity Survey. Dietary intake was assessed using validated 24-h dietary recalls on school days. Descriptive statistics were undertaken to determine energy, nutrients, food groups and food products consumed during school hours, as well as their contributions to total daily intake. Associations between school food intake and socio-demographic characteristics were explored. Setting: Australia. Participants: Seven hundred and ninety-five children aged 5-12 years. Results: Children consumed 37 % of their daily energy and 31-43 % of select nutrient intake during school hours, with discretionary choices contributing 44 % of school energy intake. Most children consumed less than one serve of vegetables, meat and alternatives or milk and alternatives during school hours. Commonly consumed products were discretionary choices (34 %, including biscuits, processed meat), bread (17 %) and fruit (12 %). There were limited associations with socio-economic position variables, apart from child age. Conclusions: Children's diets were not aligned with national recommendations, with school food characterised by high intake of discretionary choices. These findings are consistent with previous Australian evidence and support transformation of the Australian school food system to better align school food consumption with recommendations.

Background: There is significant opportunity to improve the nutritional quality of foods packed in children's school lunchboxes. Interventions that are effective and scalable targeting the school and home environment are therefore warranted. Objective: This study aimed to assess the effectiveness of a multicomponent, mobile health-based intervention, SWAP IT, in reducing the energy contribution of discretionary (ie, less healthy) foods and drinks packed for children to consume at school. Methods: A type I effectiveness-implementation hybrid cluster randomized controlled trial was conducted in 32 primary schools located across 3 local health districts in New South Wales, Australia, to compare the effects of a 6-month intervention targeting foods packed in children's lunchboxes with those of a usual care control. Primary schools were eligible if they were not participating in other nutrition studies and used the required school communication app. The Behaviour Change Wheel was used to co-design the multicomponent SWAP IT intervention, which consisted of the following: school lunchbox nutrition guidelines, curriculum lessons, information pushed to parents digitally via an existing school communication app, and additional parent resources to address common barriers to packing healthy lunchboxes. The primary outcome, mean energy (kilojoules) content of discretionary lunchbox foods and drinks packed in lunchboxes, was measured via observation using a validated school food checklist at baseline (May 2019) and at 6-month follow-up (October 2019). Additional secondary outcomes included mean lunchbox energy from discretionary foods consumed, mean total lunchbox energy packed and consumed, mean energy content of core lunchbox foods packed and consumed, and percentage of lunchbox energy from discretionary and core foods, all of which were also measured via observation using a validated school food checklist. Measures of school engagement, consumption of discretionary foods outside of school hours, and lunchbox cost were also collected at baseline and at 6-month follow-up. Data were analyzed via hierarchical linear regression models, with controlling for clustering, socioeconomic status, and remoteness. Results: A total of 3022 (3022/7212, 41.90%) students consented to participate in the evaluation (mean age 7.8 years; 1487/3022, 49.22% girls). There were significant reductions between the intervention and control groups in the primary trial outcome, mean energy (kilojoules) content of discretionary foods packed in lunchboxes (-117.26 kJ; 95% CI -195.59 to -39.83; P=.003). Relative to the control, the intervention also significantly reduced secondary outcomes regarding the mean total lunchbox energy (kilojoules) packed (-88.38 kJ; 95% CI -172.84 to -3.92; P=.04) and consumed (-117.17 kJ; 95% CI -233.72 to -0.62; P=.05). There was no significant difference between groups in measures of student engagement, consumption of discretionary foods outside of school hours, or cost of foods packed in children's lunchboxes. Conclusions: The SWAP IT intervention was effective in reducing the energy content of foods packed for and consumed by primary school-aged children at school. Dissemination of the SWAP IT program at a population level has the potential to influence a significant proportion of primary school-aged children, impacting weight status and associated health care costs.

Abstract Objective: The aim of the study was to assess the impact of different lunchbox messages on parents' intention to pack a healthy lunchbox. Design: This study employed an experimental design. Setting: A series of messages were developed to align with the six constructs of the Health Belief Model. Messages were also developed that were (and were not) personalised and varied based on the source of the information provided (university, school, dietitian and health promotion service). During a telephone survey, participants were read the content of each message and asked about their intention to pack a healthy lunchbox. Participants: Parents of primary school-aged children were randomised to receive different messages to encourage the packing of healthy lunchboxes. Results: The study was completed by 511 parents. Linear mixed regression analyses identified significant differences (P < 0·05) in intention scores between variant messages targeting the same behavioural constructs for 'susceptibility', 'severity', 'benefits' and 'barriers' but not 'cues to action' or 'self-efficacy'. The highest mean behavioural intention score was for 'benefits', whilst the lowest mean score was for 'barriers'. There were no significant differences in intention scores of parents receiving messages from a dietitian, university, health promotion team or school (P = 0·37). Intention scores did not differ in which messages were personalised based on child's name (P = 0·84) or grade level (P = 0·54). Conclusions: The findings suggest that messages that focus on the benefits of packing healthy lunchboxes may be particularly useful in improving intentions of parents to pack healthy foods for their children to consume at school.

Background: Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention. Methods: A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects. Results: At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student). Conclusions: The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

Empirical studies to disentangle the effects of multicomponent implementation interventions are needed to inform the development of future interventions. This study aims to examine which behavior change techniques (BCTs) primarily targeting canteen manager are associated with school's healthy canteen policy implementation. This is a secondary data analysis from three randomized controlled trials assessing the impact of a "high,""medium,"and "low"intensity intervention primarily targeting canteen managers on school's implementation of a healthy canteen policy. The policy required primary schools to remove all "red"(less healthy items) or "banned"(sugar sweetened beverages) items from regular sale and ensure that "green"(healthier items) dominated the menu (>50%). The delivery of BCTs were retrospectively coded. We undertook an elastic net regularized logistic regression with all BCTs in a single model. Five k-fold cross-validation elastic net models were conducted. The percentage of times each strategy remained across 1,000 replications was calculated. For no "red"or "banned"items (n = 162), the strongest BCTs were: problem solving, goal setting (behavior), and review behavior goals. These BCTs were identified in 100% of replications as a strong predictor in the cross-validation elastic net models. For the outcome relating to >50% "green"items, the BCTs problem solving, instruction on how to perform behavior and demonstration of behavior were the strongest predictors. Two strategies were identified in 100% of replications as a strong (i.e., problem solving) or weak predictor (i.e., feedback on behavior). This study identified unique BCTs associated with the implementation of a healthy canteen policy.

The aim of this study was to develop a risk prediction model for high risk adenomas (HRAs) detected at screening colonoscopy based on readily available participant information. The cohort consisted of 3035 participants aged 50 to 74 years with no history of cancer who underwent a primary screening colonoscopy at a centralized colon cancer screening centre between 2008 and 2016. A multivariable logistic regression model was created using CRC risk factors identified from prior research. Model covariates were collected from a baseline questionnaire and included participant demographics (age and sex), lifestyle parameters (body mass index, alcohol, smoking, and vitamin D supplement use) and medical history (family history of CRC and diabetes). Mean participant age was 58.8 years, and 54.7% were male. 249 participants with HRAs were identified (8.2%). An adjusted c-statistic of 0.67 was calculated, and a specificity and negative predictive value of 97.2% (95% CI: 96.5¿97.8) and 92.5% (95% CI: 92.2¿92.8) for the detection of HRAs, respectively, were achieved using 20% predicted probability as a high-risk threshold. However, only a sensitivity of 12.1% (95% CI: 8.3¿16.8) was achieved. Our model has moderate predictive ability, with strengths in being able to rule out those with an absence of HRAs on screening colonoscopy. Maximizing screening efficiency through improved risk prediction can enhance resource allocation. Ultimately, this model has the potential to improve patient care by reducing unnecessary colonoscopies, limiting this invasive procedure to those most likely to have significant findings.

Objective: This study assessed the effectiveness of a school-based intervention in reducing adolescents¿ sugar-sweetened beverage (SSB) consumption and percentage of energy from SSBs. Secondary outcomes were SSB consumption within school, average daily energy intake, and body mass index z-scores. Methods: Six secondary schools located in New South Wales, Australia were recruited to participate in a six-month pilot randomised controlled trial (1:1). The intervention included components targeting the school nutrition environment, curricula and community. Outcomes were collected via online surveys, observations, anthropometric measurements and project records. Between-group differences were assessed via linear mixed models. Results: At the six-month intervention endpoint (n=862) there were no statistically significant differences between students in intervention or control schools for mean daily intake of SSBs (8.55mL; CI -26.77, 43.87; p=0.63), percentage daily energy from SSBs (0.12% kJ; CI -0.55, 0.80; p=0.72), or for secondary outcomes. Acceptability of the school-based strategies were high, however intervention fidelity varied across schools. Conclusion: While acceptable, improving fidelity of implementation and increasing the duration or intensity of the intervention may be required to reduce SSB intake. Implications for public health: Engaging parents and education stakeholders in the development phase to co-design interventions may prove beneficial in improving intervention fidelity and enhance behavioural outcomes.

Objective: To assess differences between traditional paper bag ordering and online ordering from primary school canteens in terms of menu, usage and lunch order characteristics. Design: A cross-sectional study. Setting: New South Wales (NSW) primary schools that offered both paper bag and online canteen ordering. Participants: Students (aged 5-12 years) with a lunch order on the day of the observation. Results: Across the six school canteens, 59-90 % of all available items were listed on both the online and paper menus, with no significant differences in the nutritional quality ('Everyday'/'Occasional') or nutritional content (kJ/saturated fat/sugar/sodium) of menu items. In total, 387 student lunch orders were placed, containing 776 menu items. Most orders (68 %) were placed online. There were no significant differences between order modality in the quantity of items ordered or the cost of orders, or the nutritional quality of orders based on the classification system of the NSW Healthy School Canteen Strategy ('Everyday'/'Occasional'). However, nutritional analysis revealed that paper bag orders contained 222 fewer kJ than online orders (P = 0·001), 0·65 g less saturated fat (P = 0·04) and 4·7 g less sugar (P < 0·001). Conclusions: Online canteens are commonly used to order canteen lunches for primary school children. This is the first study to investigate differences between traditional paper bag ordering and online ordering in this setting. Given the rapid increase in the use of online ordering systems in schools and other food settings and their potential to deliver public health nutrition interventions, additional research is warranted to further investigate differences in ordering modalities.

Issue addressed: Healthy canteen policies regulating the sales of food and beverages are available across all the states and territories in Australia. The aim of this study was to assess the compliance with a newly updated healthy school canteen policy in New South Wales (NSW) among a sample of secondary schools. Methods: A cross-sectional study of secondary school canteen menus was undertaken in selected regions across NSW (September 2017-November 2017). Government and Catholic secondary schools with a canteen menu publicly available on school websites were eligible for inclusion. Menus were classified according to the NSW Healthy School Canteen Strategy using a Quick Menu Audit tool, previously validated in primary schools. Results: Of 62 Catholic and 128 Government secondary schools located in the study region, 53 secondary schools (25 Catholic and 28 Government) were eligible to participate. The average percentage of ¿everyday¿ (healthy) items on secondary school menus was 54% (strategy criteria is >75%). Twenty-eight per cent of menus had no ¿sugary drinks¿ (should not be sold). None of the 53 menus assessed met all strategy criteria regarding the availability of foods and beverages. There was no statistically significant difference in meeting; (a) 75% minimum ¿everyday¿ items and (b) no ¿sugary drinks,¿ by socio-economic region, remoteness, school enrolments or school type. Conclusions: If public health benefits of healthy eating policies are to be realised, secondary schools need to be supported to implement such policies. So what?: Future research assessing the impact of intervention strategies to support policy implementation in secondary schools is recommended.

Unhealthy dietary patterns in adolescence are associated with an increased risk of future chronic disease. This study aimed to assess online canteen lunch purchases made by high school students to identify: (1) the nutrient composition of purchases (energy, saturated fat, sugar, sodium, percent energy from saturated fat and total sugar); (2) the proportion of items classified as healthier (¿Everyday¿) and less healthy (¿Occasional¿ or ¿Should not be sold¿) according to the New South Wales Healthy Canteen Strategy; (3) the frequency of purchases by product type (e.g., salty snacks), their classification and nutrient composition; and (4) associations between student characteristics and the nutrient composition and classification of purchases. The average order contained 2075 kJ of energy, 6.4 g of saturated fat, 18.4 g of sugar and 795 mg of sodium. Less healthy (¿Occasional¿ and ¿Should not be sold¿) items combined accounted for 56% of purchases. The most frequently purchased products were burgers and crumbed/coated foods. Students in higher grades purchased a significantly higher mean percent of ¿Everyday¿ items, compared to students in grades 7 or 8. The majority of high school student purchases were less healthy (¿Occasional¿ or ¿Should not be sold¿) items, warranting further investigation of factors influencing online canteen purchasing behaviour in this setting.

Aim: To (a) describe lunchbox foods packed and consumed by children attending early childhood education and care services; (b) compare the serves of foods packed and consumed with nutrition guideline recommendations; and (c) explore associations between parent characteristics and serves of food groups packed in lunchboxes. Methods: A cross sectional study was conducted on a sample of early childhood education and care services where parents provide food in the Hunter New England region of NSW, Australia. Lunchbox contents were assessed using photography and pre- and post-meal weights. Descriptive statistics were used to describe packing and consumption of core food groups and discretionary foods. Results: Data on food packed and consumed were collected for 355 children's lunchboxes from 17 services (preschools n¿=¿14, long day care services n¿=¿3). Less than half (44%) of lunchboxes contained vegetables, and 54% contained at least one serve of discretionary foods. Less than 1% of lunchboxes met all setting-specific nutrition guidelines. On average, children consumed 68% of lunchbox contents, with the lowest consumption rate being for vegetables. An association was found between parent education level and packing of discretionary foods (-0.36, P¿= <.01) but not for packing of fruit or vegetables. Conclusions: Lunchboxes contained an over-representation of discretionary foods and under-representation of vegetables, and children had a low preference for consuming vegetables compared with other food groups. Interventions to support parent packing of lunchboxes in line with nutrition guidelines and strategies to expand child preference for foods such as vegetables are warranted.

There has been a proliferation of digital health interventions (DHIs) targeting dietary in-take. Despite their potential, the effectiveness of DHIs are thought to be dependent, in part, on user engagement. However, the relationship between engagement and the effectiveness of dietary DHIs is not well understood. The aim of this review is to describe the association between DHI engagement and dietary intake. A systematic search of four electronic databases and grey literature for records published before December 2019 was conducted. Studies were eligible if they examined a quantitative association between objective measures of engagement with a DHI (subjective experience or usage) and measures of dietary intake in adults (aged = 18 years). From 10,653 citations, seven studies were included. Five studies included usage measures of engagement and two examined subjective experiences. Narrative synthesis, using vote counting, found mixed evidence of an association with usage measures (5 of 12 associations indicated a positive relationship, 7 were in-conclusive) and no evidence regarding an association with subjective experience (both studies were inconclusive). The findings provide early evidence supporting an association between measures of usage and dietary intake; however, this was inconsistent. Further research examining the association between DHI engagement and dietary intake is warranted.

Background: To determine Australian primary school principals', teachers', and parents' attitudes to changing school uniform policies to allow students to wear sports uniforms every day and to assess associations between participant characteristics and their attitudes. A secondary aim was to identify principals' and teachers' perceived barriers to uniform changes. Methods: Cross-sectional surveys of principals, teachers, and parents of children in grades 2 to 3 (age 7-10 y) from 62 Australian primary schools (Oct 2017-Mar 2018) were undertaken. Mixed logistic regression analyses assessed the associations between participant characteristics and attitudes toward uniform changes. Results: In total, 73% of the principals (38/52) who responded reported that their school only allowed children to wear a sports uniform on sports days. Overall, 38% of the principals (18/47), 63% of the teachers (334/579), and 78% of the parents (965/1231) reported they would support a policy that allowed children to wear daily sports uniforms. The most commonly reported barrier was the perception that sports uniforms were not appropriate for formal occasions. Conclusions: Although the majority of the principals were not supportive of a change to a daily sports uniform, the majority of the teachers and parents were. Strategies to improve principal support may be required if broader adoption of physical activity-supporting uniforms is to be achieved.

Aim: To assess the impact of a multistrategy intervention designed to improve teachers' implementation of a school physical activity (PA) policy on student PA levels. Methods: A cluster-randomized controlled trial was conducted in 12 elementary schools. Policy implementation required schools to deliver 150 minutes of organized PA for students each week via physical education, sport, or class-based activities such as energizers. Schools received implementation support designed using the theoretical domains framework to help them implement the current policy. Results: A total of 1,502 children in kindergarten to grade 6 participated. At follow-up compared with control, students attending intervention schools had, measured via accelerometer, significantly greater increases in school day counts per minute (97.5; 95% confidence interval [CI], 64.5 to 130.4; P <.001) and moderate to vigorous physical activity (MVPA) (3.0; 95% CI, 2.2-3.8, P <.001) and a greater decrease in sedentary time (-2.1; 95% CI, -3.9 to -0.4, P =.02) per school day. Teachers in intervention schools delivered significantly more minutes (36.6 min) of PA to their students at follow-up (95% CI, 2.7-70.5, P =.04). Conclusions: Supporting teachers to implement a PA policy improves student PA. Additional strategies may be needed to support teachers to implement activities that result in larger gains in student MVPA.

There is suggestive evidence for the role of vitamin D in the development of colorectal cancer (CRC). Due to high latitudes in Canada, many Canadians are vitamin D deficient throughout winter. In this analysis, we examined the association between vitamin D supplement use and high-risk adenomatous polyps (HRAPs). The study population was drawn from the biorepository at the Forzani & MacPhail Colon Cancer Screening Centre (CCSC) in Calgary. Individuals enrolled between 2013 and 2016 between the age of 50 and 74 years (n = 1409) were included. When examining the association between any supplemental vitamin D use and HRAPs, a protective effect is observed with an ORadj of 0.57 (95% CI: 0.33¿0.96). Similarly, meeting the recommended daily intake (RDI) of vitamin D (600 IU) is protective against HRAPs with an ORadj of 0.78 (95% CI: 0.62¿0.99). This study suggests that adequate vitamin D supplementation reduces the occurrence of colorectal polyps in high-latitude locations.

Background: Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group. Methods: We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, and Web of Science from database inception to June 2018 for eligible interventional studies aimed at reducing frequent ED utilization among adult patients with CNCP. Articles were assessed in duplicate in accordance with methodologic recommendations from the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes of interest were the frequency of subsequent ED visits, type and amount of opioids administered in the ED and prescribed at discharge, and costs. Methodologic quality was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias tools for nonrandomized and randomized studies, respectively. Results: Thirteen studies including 1,679 patients met the inclusion criteria. Identified interventions implemented pain policies (n¿= 4), individualized care plans (n¿= 5), ED care coordination (n¿= 2), chronic pain management pathways (n¿= 1), and behavioral health interventions (n¿= 1). All of the studies reported a decrease in ED visit frequency following their respective interventions. These reductions were especially pronounced in studies whose interventions were focused around individualized care plans and primary care involvement. Interventions implementing opioid restriction and pain management policies were largely successful in reducing the amounts of opioid medications administered and prescribed in the ED. Conclusions: Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.

Background & Aims: In addition to monitoring adverse events (AEs) and post-colonoscopy colorectal cancers (PCCRC), indicators for assessing colonoscopy quality include adenoma detection rate (ADR) and cecal intubation rate (CIR). It is unclear whether there is an association between annual colonoscopy volume and ADR, CIR, AEs, or PCCRC. Methods: We searched publication databases through March 2019 for studies assessing the relationship between annual colonoscopy volume and outcomes, including ADR, CIR, AEs, or PCCRC. Pooled odds ratios (ORs) were calculated using DerSimonian and Laird random effects models. Sensitivity analyses were performed to assess for potential methodological or clinical factors associated with outcomes. Results: We performed a systematic review of 9235 initial citations, generating 27 retained studies comprising 11,276,244 colonoscopies. There was no association between procedural volume and ADR (OR, 1.00; 95% CI, 0.98¿1.02 per additional 100 annual procedures). CIR improved with each additional 100 annual procedures (OR, 1.17; 95% CI, 1.08¿1.28). There was a non-significant trend toward decreased overall AEs per additional 100 annual procedures (OR, 0.95; 95% CI, 0.90¿1.00). There was considerable heterogeneity among most analyses. Conclusions: In a systematic review and meta-analysis, we found higher annual colonoscopy volumes to correlate with higher CIR, but not with ADR or PCCRC. Trends toward fewer AEs were associated with higher annual colonoscopy volumes. There are few data available from endoscopists who perform fewer than 100 annual colonoscopies. Studies are needed on extremes in performance volumes to more clearly elucidate associations between colonoscopy volumes and outcomes.

There is a need for effective interventions that improve the health and wellbeing of school and childcare staff. This review examined the efficacy of workplace interventions to improve the dietary, physical activity and/or sleep behaviours of school and childcare staff. A secondary aim of the review was to assess changes in staff physical/mental health, productivity, and students¿ health behaviours. Nine databases were searched for controlled trials including randomised and non-randomised controlled trials and quasi-experimental trials published in English up to October 2019. PRISMA guidelines informed screening and study selection procedures. Data were not suitable for quantitative pooling. Of 12,396 records screened, seven articles (based on six studies) were included. Most studies used multi-component interventions including educational resources, work-based wellness committees and planned group practice (e.g., walking groups). Multiple outcomes were assessed, findings were mixed and on average, there was moderate risk of bias. Between-group differences in dietary and physical activity behaviours (i.e., fruit/vegetable intake, leisure-time physical activity) favoured intervention groups, but were statistically non-significant for most outcomes. Some of the studies also showed differences favouring controls (i.e., nutrient intake, fatty food consumption). Additional robust studies testing the efficacy of workplace interventions to improve the health of educational staff are needed.

Although it is recommended that childcare centers provide foods consistent with dietary guidelines, the impact of implementing sector-specific guidelines on child outcomes is largely unknown. Objectives: This study aims to examine the impact of a web-based program and support to implement dietary guidelines in childcare centers on children's 1) diet; 2) BMI z scores; and 3) child health-related quality of life (HRQoL). Methods: This study was a cluster-randomized controlled trial utilizing a Type-3 Hybrid implementation-effectiveness design conducted between October 2016 and March 2018. This study reports on child outcomes. Fifty-four childcare centers in New South Wales, Australia were randomly assigned to the intervention (a web-based menu-planning tool and support) or control group (usual care). The intervention was designed to address barriers and enablers to dietary guideline implementation according to the Theoretical Domains Framework. A quota of 35 consenting childcare centers undertook child-level evaluation of dietary intake where 522 parents consented to completing =1 component of data collection for their child. Child consumption of core and discretionary (unhealthy) foods while in care was assessed via dietary observations by blinded research assistants, childcare diet quality was assessed via educator-completed questionnaires, BMI z scores were assessed via measured weight and height, and child HRQoL was assessed via parent report at baseline and 12-mo follow-up. Results: There was a significant increase in mean child consumption of fruit (0.39 servings; 95% CI: 0.12, 0.65 servings) and dairy foods (0.38 servings; 95% CI: 0.19, 0.57 servings) and a significant reduction in consumption of discretionary foods (-0.40 servings; 95% CI: -0.64, -0.16 servings) in care in the intervention group, relative to control at 12-mo follow-up. No significant differences were observed in diet quality, BMI z scores, or HRQoL. Conclusions: A web-based intervention to support planning of childcare menus consistent with dietary guidelines can improve child consumption of healthier foods in daycare. This trial was registered at www.anzctr.org.au as ACTRN12616000974404.

Objective: The present study describes the energy content of primary-school children's lunchboxes and the proportion of lunchbox foods considered discretionary. Subgroup analyses by sex, socio-economic status, age and weight status were undertaken.Design: A cross-sectional study was conducted. Mean kilojoule content, number of items and categorisation of foods and drinks in lunchboxes as 'everyday' (healthy) or discretionary (sometimes) foods were assessed via a valid and reliable lunchbox observational audit.Setting: Twelve Catholic primary schools (Kindergarten-Grade 6) located in the Hunter region of New South Wales, Australia.Participants: Kindergarten to Grade 6 primary-school students.Results: In total, 2143 children (57 %) had parental consent to have their lunchboxes observed. School lunchboxes contained a mean of 2748 kJ, of which 61·2 % of energy was from foods consistent with the Australian Dietary Guidelines and 38·8 % of energy was discretionary foods. The proportion of lunchboxes containing only healthy foods was 12 %. Children in Kindergarten-Grade 2 packed more servings of 'everyday' foods (3·32 v. 2·98, P < 0·01) compared with children in Grades 3-6. Children in Grades 3-6 had a higher percentage of energy from discretionary foods (39·1 v. 33·8 %, P < 0·01) compared with children in Kindergarten-Grade 2 and children from the most socio-economically disadvantaged areas had significantly higher total kilojoules in the school lunchbox compared with the least disadvantaged students (2842 v. 2544 kJ, P = 0·03).Conclusions: Foods packed within school lunchboxes may contribute to energy imbalance. The development of school policies and population-based strategies to support parents overcome barriers to packing healthy lunchboxes are warranted.

Detection of non-wear periods is an important step in accelerometer data processing. This study evaluated five non-wear detection algorithms for wrist accelerometer data and two rules for non-wear detection when non-wear and sleep algorithms are implemented in parallel. Non-wear algorithms were based on the standard deviation (SD), the high-pass filtered acceleration, or tilt angle. Rules for differentiating sleep from non-wear consisted of an override rule in which any overlap between non-wear and sleep was deemed non-wear; and a 75% rule in which non-wear periods were deemed sleep if the duration was < 75% of the sleep period. Non-wear algorithms were evaluated in 47 children who wore an ActiGraph GT3X+ accelerometer during school hours for 5¿days. Rules for differentiating sleep from non-wear were evaluated in 15 adults who wore a GeneActiv Original accelerometer continuously for 24¿hours. Classification accuracy for the non-wear algorithms ranged between 0.86¿0.95, with the SD of the vector magnitude providing the best performance. The override rule misclassified 37.1¿minutes of sleep as non-wear, while the 75% rule resulted in no misclassification. Non-wear algorithms based on the SD of the acceleration signal can effectively detect non-wear periods, while application of the 75% rule can effectively differentiate sleep from non-wear when examined concurrently.

Increasing population levels of physical activity (PA) can assist in achieving the United Nations sustainable development goals, benefiting multiple sectors and contributing to global prosperity. Practices and policies to increase PA levels exist at the subnational, national, and international levels. In 2018, the World Health Organization launched the first Global Action Plan on Physical Activity (GAPPA). The GAPPA provides guidance through a framework of effective and feasible policy actions for increasing PA, and requires engagement and advocacy from a wide spectrum of stakeholders for successful implementation of the proposed actions. Early career professionals, including researchers, practitioners, and policymakers, can play a major role with helping ¿all people being regularly active¿ by contributing to 4 overarching areas: (1) generation¿of evidence, (2) dissemination¿of key messages and evidence, (3) implementation¿of the evidence-based actions proposed in the GAPPA, and (4) contributing to advocacy for robust national action plans on PA. The contribution of early career professionals can be achieved through 5 pathways: (1) research, (2) workplace/practice, (3) business, (4) policy, and (5) professional and public opinion. Recommendations of how early career professionals can contribute to the generation, dissemination, and implementation of the evidence and actions proposed by the GAPPA are provided.

Importance: Recent evidence has shown that although the incidence of colorectal cancer (CRC) is decreasing among older adults, rates have increased in adults younger than 50 years. Given that younger adults are typically classified as at low risk for the disease, this epidemiologic shift is cause for concern. Objective: To analyze Canadian national cancer incidence registries to determine incidence trends for CRC among older and younger adults, updated to 2015. Design, Setting, and Participants: This cohort study determined the incidence of CRC using data from the National Cancer Incidence Reporting System (1969-1992) and the Canadian Cancer Registry (1992-2015). All Canadians diagnosed with CRC from January 1, 1969, through December 31, 2015, were included in this study. Trends among men and women were examined separately and by age category (>50 vs <50 years). Birth cohort models were fit using 5-year groups starting in 1886, with 1936 as the reference cohort. Data were analyzed from May 13, 2018 to May 16, 2018. Main Outcomes and Measures: Annualized percentage changes and incidence rate ratios of CRC. Results: From 1971 to 2015, 688515 incident cases (52.9% women) of CRC were identified. Although the incidence of CRC has decreased in older men and women, rates among younger men and women have increased since 2006 and 2010, respectively. For women younger than 50 years, incidence has increased with a mean annual percentage change of 4.45% since 2010; for men younger than 50 years, a mean annual percentage change of 3.47% from 2006 through 2015. There was an association between CRC incidence and birth cohort, with more recent cohorts being at greater risk than those born earlier. For men, the risk of colorectal cancer in the youngest cohort is more than double that of the reference (incidence rate ratio, 2.57; 95% CI, 1.32-5.02). Incidence rate ratios were not significant for women (IRR, 2.12; 95% CI, 0.95-4.70) but increased in successively younger cohorts. Conclusions and Relevance: This study found increasing incidence of colorectal cancer diagnoses among Canadian men and women younger than 50 years of age. This increase in incidence among a low-risk population calls for additional research on possible risk factors that may be affecting these younger cohorts. It appears that primary prevention should be the highest priority to reduce the number of younger adults developing CRC in the future..

Issue addressed: This study aimed to assess the feasibility and acceptability of using an existing school-based mobile communication application to deliver messages to parents on how to pack a healthy lunchbox. Methods: A telephone survey was conducted with 196 primary school principals within the Hunter New England region of New South Wales, Australia, in 2016. Results: Almost two thirds of primary schools (59%) currently use a school-based mobile communication application to communicate with parents. Most principals (91%) agreed school lunchboxes need improving, of which 80% agree it is a school's role to provide information and guidelines to parents. However, only 50% of principals reported currently providing such information. The provision of lunchbox messages to parents by a third party appeared an acceptable model of delivery by principals. Larger schools and schools in urban and lower socio-economic localities were more likely to have used a school-based mobile communication application. Conclusion: The majority of principals recognise student lunchboxes need improving. The use of school-based mobile communication applications appears to be feasible and acceptable by principals as a method of communicating lunchbox messages to parents. So what?: Use of school-based mobile communication applications may be an effective method for delivering health information at a population level. Future research should assess the potential efficacy of disseminating health interventions via this modality.

Objective: To assess the nutritional quality of student canteen purchases at recess and lunch, including: (i) the mean energy (kilojoules), saturated fat (grams), total sugar (grams) and Na (milligrams) and percentage of energy from saturated fat and total sugar; and (ii) the proportion and types of foods purchased that are healthier (green) and less healthy (amber/red) according to a state school canteen policy.Design: A cross-sectional study of student canteen food and beverage recess and lunch purchases.Setting: Twenty-six randomly selected government primary schools that were non-compliant with a state school canteen policy from a region of New South Wales, Australia, were approached to participate.Participants: Students (aged 5-12 years) of participating schools.Results: Eighteen schools (69 %) consented to participate. On average students' recess purchases contained 571·2 kJ energy, 1·6 g saturated fat, 11·6 g total sugar and 132·4 mg Na with 10·0 % of energy from saturated fat and 37·8 % of energy from total sugar. Students' lunch purchases contained 685·4 kJ energy, 1·8 g saturated fat, 12·7 g total sugar and 151·4 mg Na with 9·5 % of energy from saturated fat and 31·8 % of energy from total sugar. Less healthy items represented 72 and 76 % of all items purchased at recess and lunch, respectively, with 'savoury snacks' and 'sugar-sweetened ice blocks and slushies' being the most common recess and lunch purchases, respectively.Conclusions: There is considerable scope to improve the nutritional quality of student purchases from primary-school canteens, with a high percentage of energy from total sugar. Future research is required to identify effective strategies to enhance compliance with canteen policies and support the purchase of healthier foods from school canteens.

Issue addressed: School-based nutrition policies can have a positive effect on the school food environment. The primary aim of this study was to assess the primary school adherence to a mandatory state-wide healthy canteen policy 12¿months after an effective multi-strategic implementation intervention concluded. Methods: Primary schools were randomised to (a) a 12-14¿months multi-strategic intervention or (b) no-intervention (control). The intervention aimed to improve implementation of a state-wide canteen policy by encouraging schools to remove unhealthy food and beverages (classified as ¿¿red¿¿ or ¿¿banned¿¿) from canteen menus and replace with healthy items (classified as ¿¿green¿¿). No implementation support was provided to either group by the research team between the 12 and 24¿months data collection period. Results: Seventy schools participated, of which 56 schools were assessed at 24-month follow-up. Intervention schools were less likely to have a menu which contained ¿¿red/banned¿¿ items at 24-month follow-up (RR¿=¿2.28; 95% CI: 1.18-4.40; P¿=¿0.01). Intervention schools, however, were not more likely than controls to have a menu which contained >50% ¿¿green¿¿ items at 24-month follow-up (RR¿=¿1.29; 95% CI: 0.98-1.70; P¿=¿0.10). Intervention schools were more likely to adhere to both policy components (no red/banned items and >50% green items on the menu) than control schools (RR¿=¿2.61; 95% CI: 1.29-5.29; P¿=¿0.006). Among intervention schools that were fully adherent to the policy following implementation support (12-month post baseline), all were also adherent at the 24-month follow-up. Conclusion: The intervention was effective in achieving long-term school adherence to a state-wide canteen policy at 24-month follow-up. So what?: The findings suggest that sustained improvements in implementation of school nutrition policies is possible following a period (12¿months) of comprehensive implementation support.

The primary aim of this study was to assess the efficacy of a childcare-based intervention in increasing child physical activity by allowing children unrestricted access to outdoor areas for free-play when structured activity is not taking place. A randomized controlled trial was conducted in six childcare services. Intervention services provided children unrestricted access outdoors for active free-play, while control services provided their usual scheduled periods of outdoor play. Consent was obtained from 231 children. Child moderate to vigorous activity (MVPA), the primary trial outcome, was assessed via accelerometer at baseline and 3 months post baseline. Intervention effects were examined using Generalised Linear Mixed Models. Controlling for child age, gender and baseline outcome measure, at follow-up there were no significant differences between groups in minutes of MVPA in-care (mean difference: 4.85; 95% CI: -3.96, 13.66; P = 0.28), proportion of wear time in-care spent in MVPA (mean difference: 1.52%; 95% CI: -0.50, 3.53; P = 0.14) or total physical activity in-care (mean difference in counts per minute: 23.18; 95% CI: -4.26, 50.61; P = 0.10), nor on measures of child cognition (P = 0.45-0.91). It was concluded that interventions addressing multiple aspects of the childcare and home environment might provide the greatest potential to improve child physical activity.

Implementation of interventions in community organisations such as schools, childcare centres, and sporting clubs are recommended to target a range of modifiable risks of non-communicable diseases. Poor implementation, however, is common and has contributed to the failure of non-communicable disease interventions globally. This study aimed to characterise experimental research regarding strategies to improve implementation of chronic disease prevention programs in community settings. The review used data collected in three comprehensive systematic reviews undertaken between August 2015 and July 2017. Randomised controlled trials, including cluster design, and non-randomised trials with a parallel control group were included. The data were extracted to describe trial characteristics, implementation strategies employed, implementation outcomes and study quality. Of the 40 implementation trials included in the study, unhealthy diet was the most common risk factor targeted (n = 20). The most commonly reported implementation strategies were educational meetings (n = 38, 95%), educational materials (n = 36, 90%) and educational outreach visits (n = 29, 73%). Few trials were conducted ¿at-scale¿ (n = 8, 20%) or reported adverse effects (n = 5, 13%). The reporting of implementation related outcomes; intervention adoption (n = 13, 33%); appropriateness (n = 11, 28%); acceptability (n = 8, 20%); feasibility (n = 8, 20%); cost (n = 3, 8%); and sustainability (n = 2, 5%); was limited. For the majority of trials, risk of bias was high for blinding of study personnel/participants and outcome assessors. Testing of strategies to improve implementation of non-communicable disease prevention strategies in community settings, delivered ¿at-scale¿, utilising implementation frameworks, including a comprehensive range of implementation outcomes should be priority areas for future research in implementation science.

Objectives: Although evidence-based interventions (EBIs) and effective strategies to implement them exist, they cannot be used by policy makers and practitioners if they do not align with end users¿ needs. As such, adaptations to EBIs and implementation approaches are likely to occur to increase ¿fit¿ with end users¿ capacity. This article describes an approach undertaken by a population health service delivery unit in one Australian state to develop an adapted implementation strategy to support the implementation of the mandatory healthy canteen policy (EBI) to all schools located in the service delivery region. Study design: This is a case study of adapting an intervention to improve implementation of the healthy canteen policy. Methods and results: This is a six-step pragmatic, empirically driven approach. The steps include (i) adapt, where appropriate, the EBI to facilitate implementation; (ii) identify end users¿ capacity for implementation; (iii) identify opportunities to adapt the implementation interventions while preserving meaningful intervention impact; (iv) undertake program adaptation; (v) develop training and resources to support delivery of implementation strategies and; (vi) evaluate the adapted intervention. This article describes the application of these steps by the authors to develop an adapted support strategy consistent with end users¿ needs. Conclusions: This study provides some guidance on how to adapt implementation support approaches particularly when EBIs cannot be adapted. Future empirical research providing guidance on making practical adaptation decisions are needed.

Background Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers¿ likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information. Methods A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products. Results Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six ¿healthier¿ products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six ¿less healthy¿ products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying ¿healthier¿ foods (88%, n = 31). Conclusions The inclusion of product nutritional rating information has the potential to improve the availability of some ¿healthier¿ items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

Background: Schools play an important role in physical activity promotion for adolescents. The systematic review aimed to determine the proportion of secondary (middle and high) school physical education (PE) lesson time that students spend in moderate to vigorous physical activity (MVPA), and to assess if MVPA was moderated by school level (middle and high school), type of physical activity measurement and type of PE activities. Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649). Studies were eligible if they were published between 2005 and 2014; written in English; assessed MVPA in PE lessons of secondary (middle and high) school students; and used a quantitative MVPA measure (i.e., accelerometry, heart rate monitoring, pedometers or observational measures). Two reviewers examined the retrieved articles, assessed risk of bias, and performed data extraction. Random effects meta-analysis was used to calculate a pooled estimate of the percent of PE lesson time spent in MVPA and to assess moderator effects where data allowed. Results: The search yielded 5,132 potentially relevant articles; 28 articles representing 25 studies (7 middle and 18 high school) from seven countries were included. Twelve studies measured MVPA through observational measures, seven used accelerometers, five used heart rate monitors and four used pedometers (including three studies using a mix of measures). Meta-analysis of 15 studies found that overall, students spent a mean (95% CI) of 40.5% (34.8-46.2%) of PE in MVPA. Middle school students spent 48.6% (41.3-55.9%) of the lesson in MVPA (n=5 studies) and high school students 35.9% (28.3-43.6%) (n=10 studies). Studies measuring MVPA using accelerometers (n=5) showed that students spent 34.7% (25.1-44.4%) of the lesson in MVPA, while 44.4% (38.3-50.5%) was found for lessons assessed via observation (n=9), 43.1% (24.3-61.9%) of the lesson for a heart rate based study, and 35.9% (31.0-40.8%) for a pedometer-measured study. Conclusions: The proportion of PE spent in MVPA (40.5%) is below the US Centre for Disease Control and Prevention and the UK Associations for Physical Education recommendation of 50%. Findings differed according to the method of MVPA assessment. Additional strategies and intervention research are needed to build more active lesson time in PE.

Issue addressed: This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods: A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results: Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions: Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

Objective: The aims of this systematic review and meta-analysis are (i) to determine the impact of school-based interventions on objectively measured physical activity among adolescents and (ii) to examine accelerometer methods and decision rule reporting in previous interventions. Methods: A systematic search was performed to identify randomized controlled trials targeting adolescents (age: =10¿years), conducted in the school setting, and reporting objectively measured physical activity. Random effects meta-analyses were conducted to determine the pooled effects of previous interventions on total and moderate-to-vigorous physical activity. Potential moderators of intervention effects were also explored. Results: Thirteen articles met the inclusion criteria, and twelve were included in the meta-analysis. The pooled effects were small and non-significant for both total physical activity (standardized mean difference¿=¿0.02 [95% confidence interval¿=¿-0.13 to 0.18]) and moderate-to-vigorous physical activity (standardized mean difference¿=¿0.24 [95% confidence interval¿=¿-0.08 to 0.56]). Sample age and accelerometer compliance were significant moderators for total physical activity, with a younger sample and higher compliance associated with larger effects. Conclusion: Previous school-based physical activity interventions targeting adolescents have been largely unsuccessful, particularly for older adolescents. There is a need for more high-quality research using objective monitoring in this population. Future interventions should comply with best-practice recommendations regarding physical activity monitoring protocols.

Background: Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent populations. As a result, few cost effectiveness analyses have been reported. The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone (PA4E1) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities. Cost effectiveness was assessed using both the physical activity and weight status trial outcomes. Methods: Intervention and Study Design: The PA4E1 cluster randomised controlled trial was implemented in 10 Australian secondary schools (5 intervention: 5 control) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components. Costs associated with physical activity strategies, and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practices of schools in the control group. The total cost of implementing the intervention was estimated from a societal perspective, based on the number of enrolled students in the target grade at the start of the intervention (Grade 7, n = 837). Economic Outcomes: The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following: minutes of moderate-to-vigorous physical activity (MVPA) per day gained, MET hours gained per person/day; Body Mass Index (BMI) unit avoided; and 10 % reduction in BMI z-score. Results: The intervention cost AUD $329,952 over 24 months, or AUD$394 per student in the intervention group. This resulted in a cost effectiveness ratio of AUD$56 ($35-$147) per additional minute of MVPA, AUD$1 ($0.6-$2.7) per MET hour gained per person per day, AUD$1408 ($788-$6,570) per BMI unit avoided, and AUD$563 ($282-$3,942) per 10 % reduction in BMI z-score. Conclusion: PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence, a period in which physical activity typically declines. Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12612000382875.

Objective: To examine elementary school students' moderate-to-vigorous physical activity (MVPA) levels during physical education (PE) lessons. Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649). Studies were eligible if they were in English; published between 2005-April 2014; assessed MVPA levels in PE lessons of elementary school children (aged four-12 years); and used an objective MVPA measure. Two reviewers retrieved articles, assessed risk of bias, and performed data extraction. The findings were synthesised using a meta-analysis. Results: The search yielded 5132 articles. Thirteen studies from nine countries met the inclusion criteria. Eight studies measured MVPA through observational measures, five used accelerometry and one used heart rate monitoring. The percentage of PE lesson time spent in MVPA ranged between 11.4-88.5%. Meta-analysis of seven studies (direct observations; 4 accelerometers) found that children spent a mean (95% CI) 44.8 (28.2-61.4)% of PE lesson time in MVPA. When measured using direct observation and accelerometers, children spent 57.6 (47.3-68.2) and 32.6 (5.9-59.3)% of PE lesson time in MVPA, respectively. The review has limitations; the search strategy was restricted to studies in English; theses, dissertations and conference abstracts were excluded; and six studies that provided insufficient data were excluded from the meta-analysis. Conclusion: MVPA levels during elementary school PE lessons do not meet the United States Centre for Disease Control and Prevention and the United Kingdom's Association of Physical Education recommendation (50% of lesson time), but is higher than estimated in the previous review (34.2%). Interventions to increase MVPA in PE lessons are needed.

Issue addressed In order to assess the impact of healthy school canteen policies on food availability for students, valid methods of measuring compliance are needed that can be applied at scale. The aim of this study is to assess the validity and direct cost of four methods to assess policy compliance: 1) principal and 2) canteen manager self-report via a computer-assisted telephone interview; and 3) comprehensive and 4) quick menu audits by dietitians, compared with observations. Methods A cross-sectional study took place in the Hunter region of NSW, Australia, in a sample of 38 primary schools that had previously participated in a randomised controlled trial to improve healthy canteen policy compliance. Policy compliance was assessed using the four methods specified above. Percentage agreement, kappa, sensitivity and specificity compared with observations was calculated together with the direct time taken and costs of each method. Indirect costs (including set-up costs) for all measures have not been included. Results Agreement with observations was substantial for the quick menu audit (kappa=0.68), and moderate for the comprehensive menu audit (kappa=0.42). Principal and canteen manager self-report resulted in poor agreement and low specificity with the gold standard. The self-reported measures had the lowest cost, followed by the quick menu audit and lastly the comprehensive menu audit. Conclusion The quick menu audit represents a valid and potentially low-cost method of supporting policy implementation at scale. So what? This study demonstrates that a quick menu audit represents a valid measure of undertaking assessment of school canteen policy compliance at a population level.

Objectives: Physical education (PE) plays an important role in contributing to students' physical activity (PA); however, moderate-to-vigorous PA (MVPA) within PE is lower than recommended. Little is known about the PA levels of students from disadvantaged schools within PE. This study aimed to describe: (i) the PA levels of students from disadvantaged secondary schools during PE lessons, (ii) the lesson context and teacher interactions occurring during PE, and (iii) the associations between teacher, school or PE lesson characteristics with student physical activity levels in PE. Design: Cross-sectional study of 100 Grade 7 PE lessons across 10 secondary schools. Methods: System for observing fitness instruction time (SOFIT) was used to assess student PA, lesson context, and teacher interaction. Teacher and school characteristics were collected via survey. Mean proportion of lesson time was used to describe PA, lesson context and teacher interaction. Associations between each outcome variable and each characteristic were examined using 2-sample t-tests, ANOVAs and linear regression. Results: Thirty-nine percent of PE lesson was spent in MVPA, and less than 10% spent in VA. Lessons in schools in urban areas included significantly more MVPA than rural areas (P = 0.04). Male teachers and more experienced teachers conducted lessons with significantly more VA than female and less experienced teachers (P = 0.04 and 0.02). MVPA was also higher in lessons conducted by more experienced teachers. Conclusions: PA during PE lessons within disadvantaged secondary schools is below international recommendations. Male teachers, more experienced teachers and schools in urban regions teach more active lessons.

Background: Adolescence is a recognised period of physical activity decline, particularly among low-income communities. We report the 12-month (midpoint) effects of a 2-year multicomponent physical activity intervention implemented in disadvantaged secondary schools. Methods: A cluster randomised trial was undertaken in 10 secondary schools located in disadvantaged areas in New South Wales, Australia. Students in Grade 7 were recruited, with follow-up in Grade 8. The intervention was guided by socioecological theory and included seven physical activity strategies, and six implementation adoption strategies. The primary outcome was mean minutes of moderate-to-vigorous physical activity (MVPA) per day assessed using Actigraph GT3X accelerometers. Outcome data were analysed using repeated measures linear mixed models. Results: At baseline, 1150 (93%) students participated in the data collection (mean age 12 years, 48% boys) and 1050 (79%) students participated at 12-month follow-up. By the 12-month follow-up, the six implementation adoption strategies had been used to support schools to deliver four of the seven physical activity elements. There was a significant group-by-time interaction for mean minutes of MVPA per day in favour of the intervention group (adjusted difference between groups at follow-up=3.85 min, 95% CI (0.79 to 6.91), p=0.01), including significantly more vigorous physical activity (2.45 min, p=0.01), equating to 27 min more MVPA per week. Summary: At 12-month follow-up, the intervention had reduced the decline in physical activity among adolescents from disadvantaged schools. The intervention may assist students to meet physical activity guidelines.

This is the protocol for a review and there is no abstract. The objectives are as follows: The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices that aim to promote healthy or reduce unhealthy behaviours relating to child diet, physical activity, obesity, or tobacco or alcohol use. Secondary objectives of the review are to: examine the effectiveness of implementation strategies on health behavioural (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of stakeholders involved in implementing health promoting policies, programs or practices; describe the cost or cost effectiveness of such strategies; describe any unintended adverse effects of strategies on schools, school staff or children.

Many early childhood education and care (ECEC) services fail to implement recommended policies and practices supportive of healthy eating and physical activity. The purpose of this study was to assess whether certain theoretically-based factors are associated with implementation of healthy eating and physical activity policies and practices in a sample of ECEC services. A cross-sectional survey was conducted with Service Managers of ECEC services. The survey assessed the operational characteristics, policy, and practice implementation, and 13 factors were suggested by Damschroder¿s Consolidated Framework for Implementation Research to impede or promote implementation. Logistic regression analyses found a significant association between implementation factor score and full implementation (OR 1.38; 95% CI 1.18¿1.61; p = <0.01), indicating that for every one point increase in implementation score, ECEC services were 38¿% more likely to be fully implementing the policies and practices. The findings highlight the opportunities for improving implementation of obesity prevention interventions in this setting by developing interventions that address such factors.

Introduction Schools represent a valuable setting for interventions to improve children's diets, as they offer structured opportunities for ongoing intervention. Modifications to the school food environment can increase purchasing of healthier foods and improve children's diets. This study examines the availability of healthy food and drinks, implementation of pricing and promotion strategies in Australian primary school canteens, and whether these varied by school characteristics. Methods In 2012 and 2013, canteen managers of primary schools in the Hunter New England region of New South Wales reported via telephone interview the pricing and promotion strategies implemented in their canteens to encourage healthier food and drink purchases. A standardized audit of canteen menus was performed to assess the availability of healthy options. Data were analyzed in 2014. Results Overall, 203 (79%) canteen managers completed the telephone interview and 170 provided menus. Twenty-nine percent of schools had menus that primarily consisted of healthier food and drinks, and 11% did not sell unhealthy foods. Less than half reported including only healthy foods in meal deals (25%), labeling menus (43%), and having a comprehensive canteen policy (22%). A significantly larger proportion of schools in high socioeconomic areas (OR=3.0) and large schools (OR=4.4) had primarily healthy options on their menus. School size and being a Government school were significantly associated with implementation of some pricing and promotion strategies. Conclusions There is a need to monitor canteen environments to inform policy development and research. Future implementation research to improve the food environments of disadvantaged schools in particular is warranted.

Introduction: A number of jurisdictions internationally have policies requiring schools to implement healthy canteens. However, many schools have not implemented such policies. One reason for this isthat current support interventions cannot feasibly be delivered to large numbers of schools. A promising solution to support population-wide implementation of healthy canteen practices is audit and feedback. The effectiveness of this strategy has, however, not previously been assessed in school canteens. This study aims to assess the effectiveness and cost-effectiveness of an audit and feedback intervention, delivered by telephone and email, in increasing the number of school canteens that have menus complying with a government healthy-canteen policy. Methods and analysis: Seventy-two schools, across the Hunter New England Local Health District in New South Wales Australia, will be randomised to receive the multicomponent audit and feedback implementation intervention or usual support. The intervention will consist of between two and four canteen menu audits over 12 months. Each menu audit will be followed by two modes of feedback: a written feedback report and a verbal feedback/support via telephone. Primary outcomes, assessed by dieticians blind to group status and as recommended by the Fresh Tastes @ School policy, are: (1) the proportion of schools with a canteen menu containing foods or beverages restricted for sale, and; (2) the proportion of schools that have a menu which contains more than 50% of foods classified as healthy canteen items. Secondary outcomes are: the proportion of menu items in each category ('red', 'amber' and 'green'), canteen profitability and cost-effectiveness. Ethics and dissemination: Ethical approval has been obtained by from the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. The findings will be disseminated in usual forums, including peer-reviewed publication and conference presentations.

Issue addressed: Lowering the rates of adolescent overweight and obesity is a public health priority. The implementation of nutrition policies and practices in schools is recommended by various health organisations, but there is little information on the extent of their implementation. The aim of this study is to describe the prevalence of the implementation of recommended school-level nutrition policies and practices in secondary schools in New South Wales (NSW), Australia, and reported barriers and facilitators to the adoption of such policies and practices in school plans. Methods: A cross-sectional study was undertaken with school principals and canteen managers. All eligible secondary schools in NSW were approached to participate in a telephone survey (n¿=¿440). Descriptive statistics were used to describe prevalence, and associations between school characteristics and implementation were examined using univariate statistics. Results: A total of 137 school principals and 80 canteen managers completed the survey. The implementation of practices on drinking water during class, healthy food and beverage marketing and learning opportunities regarding healthy eating was high (>90% of participating schools). The implementation of practices regarding the restriction of unhealthy drinks in school canteens, healthy school fundraisers and staff training related to healthy eating was reported in under 25% of participating schools. There were no significant differences in implementation by school sector, socio-economic status and geographic location. The main barrier to inclusion of nutrition policies and practices in the school plan was having other priorities and commitments (28.5%), and the main facilitator was support from stakeholders, the staff, students and their parents (37.2%). Conclusions: There is opportunity to improve the implementation of nutrition policies and practices in NSW secondary schools. So What?: Strategies are needed for targeting barriers. These include: gaining support from school staff, students and parents, provision of resources and funding and staff training.