Leading article
Television and food advertising: An international health threat to children?
(See paper by Zuppa et al., pages 78–84)

Obesity is now considered one of the primary child health problems in industrialised countries (1,2). Over the past few decades, obesity rates have increased two to threefold in most developed countries (1,2). As a result of these trends, rates of type 2 diabetes are increasing in youth (3). Studies have also shown that 60% of overweight children have at least one cardiovascular disease risk factor (4). Left unabated obesity may eventually cause as much preventable disease and death as cigarette smoking (5). To ameliorate obesity during childhood, improvements are needed in the dual areas of physical activity and eating behaviours. It is widely agreed that increases in obesity prevalence are related, in part, to changes in the environment that encourage a positive energy balance. These include increases in the availability and marketing of food products, and increased time spent in sedentary activities (6). Thus, macro level influences on obesity risk must be considered in developing interventions to improve weight outcomes. One macro level influence that impacts both eating behaviour and physical activity is the media. Television has been cited as a contributing factor to higher energy intakes (6). Two possible mechanisms have been proposed linking television viewing and obesity:

(1) reduced energy expenditure from excessive television viewing displacing physical activity; and

(2) increased dietary energy intake from eating during viewing or from food advertising (7).

Children view an average of almost three hours of television per day (8,9). Since television is the most widely used advertising medium, it is important to examine exposure to food messages. The study in this issue by Zuppa, Morton and Mehta is important because it documents the types of foods advertised during programs that appeal to children. They found that of the 63 hours of television taped, there were 544 food advertisements; 79% were for non-core foods of the Australian Guide to Healthy Eating. Almost half of the food advertisements were for fast foods and confectionery. Based on this data, children are exposed to one food advertisement on television every seven minutes, and the foods advertised disproportionately promote the consumption of foods high in fat, energy and sugar. As stated in the article by Zuppa and colleagues, Australian children watch an average of 23 hours of television a week. Thus, Australian children are exposed to over 10 000 food advertisements every year. Other content analyses studies (9–12) have shown results similar to the study by Zuppa et al. The majority of studies show that television food advertisements on children’s programming target highly sweetened products, and the proportion of advertisements from fast food restaurants is increasing. The study by Zuppa and colleagues, together with other studies, clearly shows that this is an international issue.

Children are being exposed to an increasing and unprecedented barrage of advertisements (13). The principal goal of commercial children’s television is to sell products to children, with food and toys being the two most frequently advertised product categories (8). The heavy marketing of high fat foods and food of low nutritional value targetted to children can be viewed as exploitation because young children do not understand that commercials are designed to sell products and do not have the cognitive ability to comprehend or evaluate advertising (8). Numerous studies have documented that children under eight years of age are developmentally unable to understand the intent of advertisements (8,13). We know that the foods advertised on television are targetted to children across several countries and predominantly for products high in fat, sugar, salt and that these foods are inconsistent with recommendations for good health. However, a critical issue is whether exposure to these food advertisements have any observable effects on children’s dietary intake, eating behaviour and weight status. One problem in assessing the impact of television food advertisements is that food advertisements and television are both pervasive and distal, and it is difficult to conduct studies to distinguish effects from confounding variables. Compared to content analyses studies, there have been fewer studies on actual eating behaviour, and most of these studies were conducted in the 1970s and 1980s. The majority of correlational and experimental studies have shown that the amount of time spent viewing television directly correlates with children’s food requests, preferences, purchase and consumption of foods advertised on television. For example, Taras et al. (14) interviewed 66 mothers of children aged three to eight years, to assess children’s viewing habits and children’s requests for food advertised on television. The foods that children requested most frequently because they had seen them on television were the foods most frequently advertised on television. Weekly viewing hours correlated significantly with:

(1) reported number of requests by children, and purchases by parents of foods advertised on television; and

(2) children’s energy intake; children who watched more television consumed more calories.

These results were similar to those of Galst and White (15) who observed child–mother interaction in the supermarket and then interviewed mothers on their child’s television viewing habits. They found that children’s television viewing hours correlated with consumption of foods advertised on television and children’s attempts to influence their mother’s food purchases.

Controlled experimental studies with children have also demonstrated direct effects of exposure to advertising for high energy foods and snack-food choices and consumption. To date, no studies have shown the effect of television food advertising on actual weight status. Increasing amounts of time watching television has been associated with higher intakes of energy, fat, sweet and salty snacks, and carbonated beverages, and lower intakes of fruit and beverages (11). In addition, several large studies have documented associations between number of hours of television watched and the prevalence and incidence of obesity (11). We need the next generation of studies to delve into exposure to television food advertisements and impact on obesity risk and overall dietary intake patterns.

It is evident from the study by Zuppa et al., as well as other studies (9–12), that food advertisements aimed at young children attempt to persuade them to adopt eating patterns contrary to the principles of healthy eating. This is an important public health issue that warrants an international dialogue to discuss ethical concerns and social responsibility towards children, as well as policy, advocacy and education issues and actions to ensure that messages reaching children are in their best interests.

Mary Story, PhD, RD
Professor, Division of Epidemiology and
Associate Dean for Student Affairs
School of Public Health
University of Minnesota
Minneapolis, USA

Original research
Development of the Australian standard definition of child/adolescent overweight and obesity
Elizabeth Denney-Wilson, Michael L. Booth and Louise A. Baur

Abstract (Nutr Diet 2003;60:74–7)
The development of a standard definition of child and adolescent overweight and obesity for inclusion in the Australian National Health Data Dictionary is part of a strategy to address the growing prevalence of obesity among young people in Australia. A standard definition will allow more consistent data to be collected for monitoring the prevalence of overweight and obesity, for research into the causes and consequences of overweight, for public health program evaluation and for evaluating and improving clinical practice. The proposed definitions were developed following a thorough literature search and were then extensively reviewed by potential stakeholders. Body mass index is the most practical and convenient method for assessing overweight among young people, with an international reference suggested for population and clinical research, and BMI-for-age reference charts suggested for clinical practice.

Key words: body mass index, waist circumference, adiposity, anthropometry, children, adolescents, overweight, obesity

Original research
Television food advertising: Counterproductive to children’s health? A content analysis using the Australian Guide to Healthy Eating
Julie A. Zuppa, Heather Morton and Kaye P. Mehta

Abstract (Nutr Diet 2003;60:78–84)
Objective: To undertake a content analysis of the types of foods advertised during programs, which have particular appeal to children and in timeslots where children are likely to be watching television and to assess conformity with the recommendations of the Australian Guide to Healthy Eating (AGHE).

Setting: Adelaide, South Australia

Methods: Sixty-three hours of programs classified as ‘C’ (programs specifically produced for children six to 13 years of age) or ‘G’ (programs for general viewing, suitable for children to view without adult supervision) were videotaped. Advertisements with the intent of selling were included in the analysis. Food advertisements were coded for type of food (using the AGHE), network stations, program classification and viewing time.

Statistics: A chi-squared test was used to see if any difference existed between the network stations, viewing times and program classification for certain types of food advertising.

Results: There were 544 food advertisements: 21% percent for core foods; and 79% for non-core foods of the AGHE. Fast foods, chocolate and confectionery made up almost 50% of food advertisements shown on television.

Conclusions: Television food advertising did not support the recommendations for healthy eating contained in the AGHE. Child viewers were exposed to a television environment that predominantly promotes foods high in fat, sugar and salt. These nutrients are associated with obesity, dental caries and chronic diseases such as cardiovascular disease and diabetes. Changes are required to create a media environment more supportive of good nutritional health and one which enables Australian children to make healthier food choices.

Original Research

In the shadow of the volcanoes: the impact of intervention on the nutrition and health status of Rwandan refugee children in Zaire two years on from the exodus
Andre Renzaho and Catherine Renzaho

Abstract (Nutr Diet 2003;60:85–91)
Objective: To evaluate the public health and nutritional situation of refugee children in Katale camp, Eastern Zaire, after two years of nutritional and health intervention from 1994 to 1996.

Design: Cross-sectional survey using a two-stage cluster sampling method. Anthropometric data were collected from 28 May 1996 to 4 June 1996. Retrospective review of food basket monitoring data over the preceding six months and the United Nations High Commission for Refugees’ weekly mortality data was conducted. Measles immunisation coverage data were surveyed simultaneously, using child health records.

Main outcome measures: Nutritional status measured by weight-for-height index (W/H), measles immunisation status, average daily energy content of the general food ration and crude mortality rate.

Setting: Katale refugee camp, Zaire, June 1996.

Analysis: Weight-for-height index and proportion of immunised children were computed using EPINUT, part of EPINFO computer package.

Results: Malnutrition was found to be most prevalent in children aged six to 29 months old (W/H ? -2 Zscore and/or oedema: 6.2%; 95% CI: 3.4%, 10.6%), among whom the malnutrition rate was almost double the overall malnutrition prevalence (W/H ? -2 Z-score and/or oedema: 3.5% (95% CI: 1.5%, 7.2%). The general food ration, although conforming to the World Food Program minimum standards of adequacy in terms of variety (being composed of cereals, oil, beans, blended cereal and legume mixes and salt), provided only 6240 kJ on average (95% CI: 5040, 7140 kJ) per person per day, thus meeting only 57% to 84% of the minimum energy requirements for an adult, and falling well below the needs for sub groups with higher nutritional requirements such as children, pregnant and breastfeeding women and the sick. Measles immunisation coverage in children nine to 59 months was 88.6%. The crude mortality rate was found to be 0.3 per 10 000 per day. Refugees received 15 litres of clean water per person per day.

Conclusion: Public health interventions in Katale camp 1994 to 1996 had reduced mortality and morbidity rates dramatically. This was not reflected in the malnutrition rates for children under five years, that remained stable after an initial fall despite two years of nutritional intervention. The factors contributed to this were related to an inadequate general food ration (due to food shortages), lack of ability to supplement the diet, (due to economic restrictions that were imposed in the camp) and inequities in the food distribution process (due to food being siphoned off by camp leaders for military purposes).

Key words: refugee camp, Zaire, malnutrition, children, chronic emergency

Review
Nutrition issues associated with spinal muscular atrophy
Sarah Leighton

Abstract (Nutr Diet 2003;60:92–6)
Spinal muscular atrophy (SMA) is one of the more common genetic conditions, with one in 40 people being carriers of the gene. Much research has been conducted into genetic identification and classification of this group of neuromuscular disorders, yet very little information is available with regard to nutrition for those affected. Spinal muscular atrophy varies in severity according to the area of gene involved. This review of recent literature gives an overview of some of the genetics of spinal muscular atrophy, as genetic influences may affect metabolism for some people with this condition. Recent research relating to nutrition for people with SMA is presented, with consideration as to how nutrition may affect quality of life for those affected with SMA.

Key words: spinal muscular atrophy, SMA, nutrition, diet

Original research
Osteoarthritis: Is more attention to nutritional health required?
Amanda Foley, Jennifer Keogh, Michelle Miller, Julie Halbert and Maria Crotty

Abstract (Nutr Diet 2003;60:97–103)
Objective: To describe the nutritional health of a sample of older adults with osteoarthritis, and to determine whether the sample had received or were interested in formal nutrition advice.

Design: Descriptive cross-sectional study. Participants completed the Australian Nutrition Screening Initiative (ANSI) tool. Body weight and knee height were measured and a questionnaire, consisting of three questions on procurement of food, interest in and access to nutrition resources, was completed.

Subjects: One hundred and five participants aged 50 years and above with osteoarthritis who were assessed as suitable to commence an exercise program within the Repatriation General Hospital, Adelaide, South Australia.

Setting: Participants were recruited from outpatient clinics, surgical waiting lists and from the community.

Main outcome measures: Body mass index (BMI), nutritional risk assessed with ANSI tool, previous nutrition counselling, interest in nutrition advice.

Statistical analysis: Descriptive statistics were used to summarise the data.

Results: The mean BMI of the sample was 30.9 ? 5.2 kg/m2. Of the total sample, 55 (52.9%) of the participants were defined as obese. Using the ANSI checklist, 45 (42.9%) subjects were assessed as being at high nutritional risk. Only eight (7.6%) subjects had received formal nutrition advice regarding their osteoarthritis, while 83 (79%) expressed an interest in receiving such advice.

Conclusion: Patients with osteoarthritis may be at risk of poor nutritional health despite being overweight or obese. There is presently no specialised dietetic service for this patient group in our setting and medical referral patterns to dietetics do not reflect the dietetic needs of this group of patients.

Key words: nutrition, osteoarthritis, obesity, body mass index

Review
Current popular ergogenic aids used in sports: a critical review
Graziela Beduschi

Abstract (Nutr Diet 2003;60:104–18)
Many athletes make extensive use of ergogenic aids in the hope that they can favourably affect athletic performance and increase lean body mass. Supplementation with creatine, glutamine, carnitine, leucine and its metabolite hydroxymethylbutyrate (HMB), and branched chain amino acids (BCAA) has been hypothesised to assist in the achievement of optimal sports performance. Despite an increasing amount of scientific evidence and popularity, uncertainty about the effectiveness and safety of these supplements still exists. A survey was undertaken of the supplements being promoted in the most popular sports magazines in Australia. Approximately one quarter of the advertisements for supplements in the magazines surveyed were for creatine (54%), glutamine (24%), HMB (20%), and BCAA (2%). A critical literature review of trials of the effect of these ergogenic aids on exercise performance trials was conducted. Creatine supplementation appears to have substantial scientific support as a safe and effective nutritional strategy to enhance exercise performance and improve training adaptations in high-intensity, short-term (? 30 seconds) exercise tasks, with limited recovery time between repetitions. Carnitine supplementation has been reported to increase exercise capacity in disease states. However, in healthy athletes carnitine was not shown to have an ergogenic effect. There was limited evidence that the use of HMB supplementation resulted in gains in strength and body mass. There was an abundance of clinical evidence supporting the requirement for exogenous glutamine in critically ill patients and in the over-training syndrome. However, for healthy subjects, the few scientific studies available suggested that glutamine is only of benefit for athletes with true deficiency. Research findings regarding the effects of BCAA supplementation are somewhat equivocal. Most reviews evaluating the central fatigue hypothesis suggest that BCAA is not an effective ergogenic supplement, nor is it ergolytic. Further research is needed for better evaluation of the safety and efficacy of many of these supplements, especially focussing on their use in specific sporting situations.

Key words: ergogenic aids, hydroxymethylbutyrate, branched chain amino acids, creatine, carnitine, glutamine, sport nutrition,
exercise

Viewpoint
Functional foods from the dietetic perspective in Malaysia
Fatimah Arshad

Abstract (Nutr Diet 2003;60:119–121)
The area of functional foods and nutraceuticals is still actively being researched. In Malaysia, the definition of functional foods is still inconclusive. However, direct selling outlets throughout the nation are flooded with these food items since they are distributed under the food supplement category and not covered by the Food and Drug Act. As scientists, dietitians require results from clinical trials before health claims can be made regarding a particular product and the issue of dose of the food component used for therapy is also questionable. Currently dietitians have to protect the consumers from false claims and high costs imposed by direct sellers. Dietitians advocate the practice of healthy lifestyle, including healthy eating via natural foods and ingredients and not costly supplements. They need to be more assertive in promoting healthy eating and lifestyle campaigns to educate the public.

Key words: functional foods, nutraceuticals

Original research
Eating and pumping: evaluating the nutrition service of the insulin pump clinic at the Royal Melbourne Hospital
Melanie Voevodin, Cheryl Steele, Kathryn Pierce and Peter G. Colman

Abstract (Nutr Diet 2003;60:122–5)
Objective: To determine the effectiveness of a nutrition information session in an insulin pump clinic in improving knowledge and food choices, and to assess patient satisfaction with the session.

Design: An eight-part self-administered questionnaire.

Subjects: Twenty-five patients who had attended insulin pump training from August 2000 to July 2001 were invited by mail to participate in the study.

Setting: Insulin pump ‘stabilisation clinic’ at The Royal Melbourne Hospital, Victoria.

Main outcome measures: Patient-rated usefulness of the written information, retention of nutrition messages, dietary changes made and best aspects of the program.

Results: Sixteen patients responded. Eleven had attended the nutrition session and of these ten received written information. Four patients reported carbohydrate counting and glycaemic index as the most useful information. Of the 11, eight demonstrated retention of messages consistent with nutrition information provided; five made dietary changes; six reported the best thing about the nutrition session was confirmation that their knowledge and food practice was in line with current recommendations; and four suggested a follow-up session and more time with the dietitian as improvements.

Conclusion: Patient-reported improvements in dietary practice and positive feedback about the nutrition sessions indicate the value of dietetic education in the insulin pump clinic. As the number of patients treated with insulin pumps increases in Australia, sharing of information and nutrition research is encouraged to develop best practice.

Key words: insulin pump, diabetes mellitus, dietary counselling, nutrition education