Analysing the use of the Australian Health Star Rating system by level of food processing

Modifying the Health Star Rating nutrient profiling algorithm to account for ultra-processing

AIM

To modify the Australian and New Zealand Health Star Rating to account for ultra-processing and compare the alignment of the modified ratings with NOVA classifications and the current Australian Dietary Guidelines classifications of core (recommended foods) and discretionary (foods to limit).

METHODS

Data was cross-sectionally analysed for 25 486 products. Four approaches were compared to the original Health Star Rating: (1) five 'negative' points added to ultra-processed products (modification 1; inclusion approach); (2) ultra-processed products restricted to a maximum of 3.0 Health Stars (modification 2; capping approach); (3 and 4) same approach used for modifications 1 and 2 but only applied to products that already exceeded 10 'negative' points from existing Health Star Rating attributes (modifications 3 and 4, respectively; hybrid approaches). Alignment occurred when products (i) received <3.5 Health Stars and were NOVA group 4 (for NOVA comparison) or discretionary (for Dietary Guidelines comparison), or (ii) received ≥3.5 Health Stars and were NOVA groups 1-3 or core.

RESULTS

All Health Star Rating modifications resulted in greater alignment with NOVA (ranging from 69% to 88%) compared to the original Health Star Rating (66%). None of the modifications resulted in greater alignment to the Dietary Guidelines classifications overall (69% to 76%, compared with 77% for the original Health Star Rating), but alignment varied considerably by food category.

CONCLUSIONS

If ultra-processing were incorporated into the Australian and New Zealand Health Star Rating, consideration of ultra-processing within the broader dietary guidance framework would be essential to ensure coherent dietary messaging to Australians.

Nutrients or processing? An analysis of food and drink items from the UK National Diet and Nutrition Survey based on nutrient content, the NOVA classification and front of package traffic light labelling

UK front of package labelling (FOPL) informs consumers on the nutrient content of food. However, FOPL does not consider food processing, and with the UK government being urged to act on ultra-processed food (UPF), whether UPF should be added to FOPL is unclear. This study compared food and drink in the UK National Diet and Nutrition Survey (NDNS) Intake24 database based on FOPL, nutrient content and NOVA classification, to understand whether UPF are covered by dietary recommendations for foods high in fat, salt and sugar. NDNS items were coded into minimally processed food (MPF), processed culinary ingredients, processed food and UPF according to the NOVA classification and FOPL traffic lights. UPF contained greater energy, fat, saturated fat (SF), total sugar (TS) and salt than MPF. UPF had a greater odds of containing red FOPL and an unhealthier overall FOPL score (OR:4·59 (95 % CI: 3·79, 5·57); OR:7·0 (95 % CI: 6·1, 8·2), respectively) and lower odds of containing green FOPL (OR:0·05 (95 % CI: 0·03, 0·10)), compared with MPFs. For items with no red FOPL, UPF still contained greater energy, fat, SF, TS and salt than MPF. However, several UPF have healthier FOPL scores. UPF had an unhealthier nutritional profile and FOPL score than MPF. For items with no red FOPL, UPF still had an unhealthier profile than MPF, with a higher energy density. Importantly, not all UPF were unhealthy according to FOPL. These results indicate partial overlap between FOPL, nutrient content and NOVA classification of UK food and drink products, with implications for UK food and drink labelling.

Comparing product healthiness according to the Health Star Rating and the NOVA classification system and implications for food labelling systems: An analysis of 25 486 products in Australia

We investigated the extent of alignment between 'healthiness' defined by a food classification system that classifies foods and beverages primarily by their nutrient composition, the Health Star Rating (HSR) and a system that considers only the degree of processing of the product, the NOVA classification system. We used data for 25 486 products contained within the George Institute for Global Health's Australian 2022 FoodSwitch Dataset. Agreement between the two systems in the proportion of products classified as 'healthier' (HSR ≥3.5 or NOVA group 1-3) or 'less healthy' (HSR <3.5 or NOVA group 4) was assessed using the κ statistic. There was 'fair' agreement (κ = 0.30, 95%CI: 0.29-0.31) between both systems in the proportion of all products classified as healthier or less healthy. Approximately one-third (n = 8729) of all products were defined as 'discordant', including 34.3% (n = 5620) of NOVA group 4 products with HSR ≥3.5 (commonly convenience foods, sports/diet foods, meat alternatives, as well as products containing non-sugar sweeteners) and 34.1% (n = 3109) of NOVA group 1-3 products with HSR <3.5 (commonly single-ingredient foods such as sugars/syrups, full-fat dairy and products specially produced to contain no ultra-processed ingredients). Our analysis strengthens the evidence for the similarities and differences in product healthiness according to a nutrient-based classification system and a processing-based classification system. Although the systems' classifications align for the majority of food and beverage products, the discordance found for some product categories indicates potential for confusion if systems are deployed alongside each other within food policies.

A novel food processing-based nutrition classification scheme for guiding policy actions applied to the Australian food supply

Unhealthy diets are a leading risk factor for non-communicable diseases and negatively impact environmental sustainability. Policy actions recommended to address dietary risk factors, such as restrictions on marketing and front-of-pack labelling, are informed by nutrition classification schemes (NCSs). Ultra-processed foods are associated with adverse population and planetary health outcomes, yet the concept is rarely incorporated in nutrition classification schemes for policy actions. This study aims to develop a novel food processing-based nutrition classification scheme for guiding policy actions. A secondary aim is to validate the scheme by classifying food and beverage items in the Australian food supply (face validity) and comparing them to the classifications of existing NCSs (convergent validity). Two versions of a model were developed, classifying foods and beverages in two steps, first using the NOVA classification system and secondly by applying upper thresholds for added free sugars and sodium, producing a binary output of either healthy or unhealthy. All food and beverage items (n = 7,322) in a dataset combining the Australian Food Composition Database (AUSNUT 2011-2013) and Mintel's Global New Product Database (2014-2019) were classified using the two models. The same dataset was also classified by the Health Star Rating system (HSR), The Australian Dietary Guidelines (ADGs), The Pan American Health Organization's Nutrient Profile Model (PAHO NPM), and the NOVA classification scheme, and pairwise agreement between all NCSs and the two models was determined (using Cohen's Kappa coefficient). A higher proportion of food categories consistent with dietary patterns that are associated with positive health outcomes, such and fruits, vegetables, and eggs were classified as healthy. And the clear majority of food categories consistent with dietary patterns associated with adverse health outcomes, such as confectionery, snack foods, and convenience foods were classified as unhealthy. The two versions of the model showed substantial agreement with NOVA and the PAHO NPM, fair agreement with the ADGs and slight to moderate agreement with the HSR system. A model NCS combining level of processing and nutrient criteria presents a valid alternative to existing methods to classify the health potential of individual foods for policy purposes.

Oh So Sweet: A Comparative Investigation of Retail Market Composition of Sweetened and Flavoured Beverages in Singapore and Australia

The consumption of sugar and non-nutritive sweeteners has been associated with poor health outcomes. The aim of this paper was to provide a comparison of the range of sweetened or flavoured beverages between two high-income countries in the Asia-Pacific region: Australia and Singapore. Following the FoodTrackTM methodology, nutrition, labelling, and price data were collected from major Australian and Singaporean supermarket chains and convenience stores. The nutrient profiles of products were tested for differences using Kruskal−Wallis and Mann−Whitney U tests. The greatest number of products collected in Australia were from the ‘carbonated beverages’ category (n = 215, 40%), and in Singapore the greatest number of products were from the ‘tea and coffee ready-to-drink’ category (n = 182, 35%). There were more calorically sweetened beverages in Singapore compared with Australia (n = 462/517 vs. n = 374/531, p < 0.001). For calorically sweetened products, the median energy of Singaporean products was significantly higher than Australian products (134 kJ vs. 120 kJ per 100 mL, p = 0.009). In Australia, 52% of sweetened or flavoured beverages displayed a front-of-pack nutrient signposting logo, compared with 34% of sweetened or flavoured beverages in Singapore. These findings also indicate that the consumption of just one serving of calorically sweetened carbonated beverages or energy drinks would exceed the WHO maximum daily free sugar recommendations.

The Nutri-Score algorithm: Evaluation of its validation process

The Nutri-Score front-of-pack label, which classifies the nutritional quality of products in one of 5 classes (A to E), is one of the main candidates for standardized front-of-pack labeling in the EU. The algorithm underpinning the Nutri-Score label is derived from the Food Standard Agency (FSA) nutrient profile model, originally a binary model developed to regulate the marketing of foods to children in the UK. This review describes the development and validation process of the Nutri-Score algorithm. While the Nutri-Score label is one of the most studied front-of-pack labels in the EU, its validity and applicability in the European context is still undetermined. For several European countries, content validity (i.e., ability to rank foods according to healthfulness) has been evaluated. Studies showed Nutri-Score's ability to classify foods across the board of the total food supply, but did not show the actual healthfulness of products within different classes. Convergent validity (i.e., ability to categorize products in a similar way as other systems such as dietary guidelines) was assessed with the French dietary guidelines; further adaptations of the Nutri-Score algorithm seem needed to ensure alignment with food-based dietary guidelines across the EU. Predictive validity (i.e., ability to predict disease risk when applied to population dietary data) could be re-assessed after adaptations are made to the algorithm. Currently, seven countries have implemented or aim to implement Nutri-Score. These countries appointed an international scientific committee to evaluate Nutri-Score, its underlying algorithm and its applicability in a European context. With this review, we hope to contribute to the scientific and political discussions with respect to nutrition labeling in the EU.

Validation of the Thumbs food classification system as a tool to accurately identify the healthiness of foods

The Thumbs food classification system was developed to assist remote Australian communities to identify food healthiness. This study aimed to assess: (1) the Thumbs system’s alignment to two other food classification systems, the Health Star Rating (HSR) and the Northern Territory School Canteens Guidelines (NTSCG); (2) its accuracy in classifying ‘unhealthy’ (contributing to discretionary energy and added sugars) and ‘healthy’ products against HSR and NTSCG; (3) areas for optimisation. Food and beverage products sold between 05/2018 and 05/2019 in fifty-one remote stores were classified in each system. System alignment was assessed by cross-tabulating percentages of products, discretionary energy and added sugars sold assigned to the same healthiness levels across the systems. The system/s capturing the highest percentage of discretionary energy and added sugars sold in ‘unhealthy’ products and the lowest levels in ‘healthy’ products were considered the best performing. Cohen’s κ was used to assess agreement between the Thumbs system and the NTSCG for classifying products as healthy. The Thumbs system classified product healthiness in line with the HSR and NTSCG, with Cohen’s κ showing moderate agreement between the Thumbs system and the NTSCG (κ = 0·60). The Thumbs system captured the most discretionary energy sold (92·2 %) and added sugar sold (90·6 %) in unhealthy products and the least discretionary energy sold (0 %) in healthy products. Modifications to optimise the Thumbs system include aligning several food categories to the NTSCG criteria and addressing core/discretionary classification discrepancies of fruit juice/drinks. The Thumbs system offers a classification algorithm that could strengthen the HSR system.

Modelling the Impact of Reducing Ultra-Processed Foods Based on the NOVA Classification in Australian Women of Reproductive Age

Women of reproductive age have a high proportion of overweight/obesity and an overall poor nutritional intake and diet quality. Nutritional modelling is a method to forecast potential changes in nutrition composition that may offer feasible and realistic changes to dietary intake. This study uses simulation modelling to estimate feasible population improvements in dietary profile by reducing ultra-processed food (UPF) consumption in Australian women of reproductive age. The simulation used weighted data from the most recent 2011–2012 National Nutrition and Physical Activity Survey. A total of 2749 women aged 19–50 years was included, and 5740 foods were examined. The highest daily energy, saturated fat, and added sugar and sodium came from UPF. Reducing UPF by 50% decreased energy intake by 22%, and saturated fat, added sugar, sodium, and alcohol by 10–39%. Reducing UPF by 50% and increasing unprocessed or minimally processed foods by 25% led to a lower estimated reduction in energy and greater estimated reductions in saturated fat and sodium. Replacement of 50% UPF with 75% of unprocessed or minimally processed foods led to smaller estimated reductions in energy and nutrients. Our results provide insight as to the potential impact of population reductions in UPF, but also increasing intake of unprocessed or minimally processed foods, which may be the most feasible strategy for improved nutritional intake.

Evaluating intake levels of nutrients linked to non-communicable diseases in Australia using the novel combination of food processing and nutrient profiling metrics of the PAHO Nutrient Profile Model

PURPOSE

To investigate intake levels of nutrients linked to non-communicable diseases in Australia using the novel combination of food processing and nutrient profiling metrics of the PAHO Nutrient Profile Model.

METHODS

Dietary intakes of 12,153 participants from the Australian Health Survey (2011-12) aged 2 + years were evaluated. Food items reported during a 24 h recall were classified using the NOVA system. The Pan-American Health Organization Nutrient Profile Model (PAHO NPM) was applied to identify processed and ultra-processed products with excessive content of critical nutrients. Differences in mean intakes and prevalence of excessive intakes of critical nutrients for groups of the population whose diets were made up of products with and without excessive content in critical nutrients were examined.

RESULTS

The majority of Australians consumed daily at least three processed and ultra-processed products identified as excessive in critical nutrients according to the PAHO NPM. Individuals consuming these products had higher intakes of free sugars (β = 8.9), total fats (β = 11.0), saturated fats (β = 4.6), trans fats (β = 0.2), and sodium (β = 1788 for adolescents and adults; β = 1769 for children 5-10 years; β = 1319 for children aged < 5 years) (p ≤ 0.001 for all nutrients) than individuals not consuming these foods. The prevalence of excessive intake of all critical nutrients also followed the same trend.

CONCLUSION

The PAHO NPM has shown to be a relevant tool to predict intake levels of nutrients linked to non-communicable diseases in Australia and, therefore, could be used to inform policy actions aimed at increasing the healthiness of food environments.

Categorizing Foods by Relative Healthfulness: A Scoping Review of Front of Pack Labelling

Worksites are a suitable platform for employees to engage in behavioral change towards a healthy lifestyle by the modification of the food environment. Grading canteen foods at worksites into categories of relative healthfulness is an important indicator in the planning of food environmental interventions. However, in the absence of mandatory front of pack (FOP) labelling in South Africa, categorizing packaged and cooked food at worksite canteens is challenging. A scoping review was conducted on FOP labelling schemes to inform the selection of a FOP labelling scheme best suited for canteen foods at worksites in South Africa. The results of the scoping study, tabulated into a narrative summary, showed that there are several well-developed approaches to classifying foods by relative healthfulness through nutrient profiling and different forms of expression. It is recommended that because worksite canteen food sales in South Africa include both packaged and cooked food, and that a general test of various labelling schemes should be conducted to determine if a directional change is made towards purchasing healthier foods. Grading foods using interpretational aides such as an adapted FOP nutrition label to the South African context into categories of relative healthfulness can be a practical tool to inform food environmental interventions at worksite canteens and beyond.

Health Star Ratings and Beverage Purchase Intentions: A Study of Australian and New Zealand Hospitality Consumers

This study examines the effects of a health star rating system on the attitudes of consumers and their purchase intentions towards beverage products sold in hospitality venues. Previous studies linking health ratings to the food and beverages of consumers mainly focus on fast-moving consumer goods and retail purchasing. However, purchasing patterns in hospitality and foodservice environments are distinct as consumers may be less concerned about health and more interested in the dining experience. Thus, this research focuses on: (1) whether the presence of health star ratings on beverage products influences the willingness of consumers to purchase in the context of the hospitality industry, and (2) identifying the demographic and psychographic factors influencing these behavioural intentions. Using Ordinary Least Squares regression to analyse data from an e-survey of 1021 consumers in Australia and New Zealand, the study found that health star ratings do have an impact on the willingness of consumers to purchase healthy beverages. Specifically, psychographic segmentation around ‘health goals’ is far more pertinent to understanding purchase behaviour in a hospitality setting than age, gender, income, or country. The findings present new insights into the importance of health star labelling on beverages and the purchase intentions of consumers.

A Multidisciplinary Perspective of Ultra-Processed Foods and Associated Food Processing Technologies: A View of the Sustainable Road Ahead

Ultra-processed foods (UPFs) are negatively perceived by part of the scientific community, the public, and policymakers alike, to the extent they are sometimes referred to as not "real food". Many observational surveys have linked consumption of UPFs to adverse health outcomes. This narrative synthesis and scientific reappraisal of available evidence aims to: (i) critically evaluate UPF-related scientific literature on diet and disease and identify possible research gaps or biases in the interpretation of data; (ii) emphasize the innovative potential of various processing technologies that can lead to modifications of the food matrix with beneficial health effects; (iii) highlight the possible links between processing, sustainability and circular economy through the valorisation of by-products; and (iv) delineate the conceptual parameters of new paradigms in food evaluation and classification systems. Although greater consumption of UPFs has been associated with obesity, unfavorable cardiometabolic risk factor profiles, and increased risk for non-communicable diseases, whether specific food processing techniques leading to ultra-processed formulations are responsible for the observed links between UPFs and various health outcomes remains elusive and far from being understood. Evolving technologies can be used in the context of sustainable valorisation of food processing by-products to create novel, low-cost UPFs with improved nutritional value and health potential. New paradigms of food evaluation and assessment should be funded and developed on several novel pillars-enginomics, signalling, and precision nutrition-taking advantage of available digital technologies and artificial intelligence. Research is needed to generate required scientific knowledge to either expand the current or create new food evaluation and classification systems, incorporating processing aspects that may have a significant impact on health and wellness, together with factors related to the personalization of foods and diets, while not neglecting recycling and sustainability aspects. The complexity and the predicted immense size of these tasks calls for open innovation mentality and a new mindset promoting multidisciplinary collaborations and partnerships between academia and industry.

Comparing the Effects of Four Front-of-Package Nutrition Labels on Consumer Purchases of Five Common Beverages and Snack Foods: Results from a Randomized Trial

BACKGROUND

Front-of-package (FOP) nutrition labeling systems differ in how they rate food and beverage products. There is a need to examine the implications of these differences, including their focus on nutrients of public health concern.

OBJECTIVE

Our aim was to examine the impacts of 4 common FOP labels on consumers' purchases of products that received conflicting ratings across FOP systems.

DESIGN

In an experimental marketplace, participants were randomized to complete a series of purchases under 1 of 5 FOP conditions: no label, "high in" nutrient labels, multiple traffic light, Health Star Rating, or a 5-color nutrition grade.

PARTICIPANTS/SETTING

A final sample of 3,584 Canadians (13 years and older) were recruited from shopping centers in March to May 2018.

MAIN OUTCOME MEASURES

Probability of purchasing was assessed for 5 product categories (100% fruit juice, plain milk, chocolate milk, cheese snacks, and diet beverages), which received conflicting ratings across the FOP conditions.

STATISTICAL ANALYSES

Separate generalized linear mixed models estimated the influence of FOP condition on 5 binary outcomes (1 = purchased, 0 = not purchased) corresponding to the product categories.

RESULTS

Few differences were observed among the full sample. Among participants who noticed the labels (n = 1,993), those in the Health Star Rating condition were 4.5 percentage points (95% CI -7.0 to -1.9) more likely to purchase 100% fruit juice (compared to multiple traffic light) and 3.3 (95% CI 0.4 to 6.2) and 3.0 percentage points (95% CI 0.1 to 6.1) more likely to purchase cheese snacks (compared to no label and "high in"). "High in" labels produced fewer purchases of chocolate milk than no label.

CONCLUSIONS

Despite some similarities, existing FOP systems differ in the extent to which they promote or dissuade purchases of common product categories. Although the Health Star Rating might encourage purchases of products with certain positive nutritional attributes, "high in" and multiple traffic light systems might more effectively discourage purchases of products contributing nutrients of public health concern.

What Is the Nutritional Composition of Ultra-Processed Food Marketed in Italy?

The present study aimed to provide a descriptive analysis of the nutrient profile of ultra-processed foods (UPFs) marketed in Italy according to three front-of-pack labeling (FOPL) schemes implemented by France, i.e., the Nutriscore; by the United Kingdom, i.e., Multiple Traffic Lights (MTL); and by Italy, i.e., the NutrInform battery. The analysis was made in fourteen food product categories, corresponding to 124 foods. The application of the Nutriscore scheme showed that a significant proportion of foods (23%) were awarded an A or B. Furthermore, the analysis according to the MTL showed that food products that were above the threshold (“red”) for fat, saturated fats, sugars, and salt ranged from 13% to 31%. Interestingly, even though all foods considered in the analysis were UPF, they were heterogeneous in nutritional composition, as demonstrated by the FOPL schemes applied, showing that UPF represent a heterogeneous group of foods with different characteristics. Such a finding may have relevant implications for epidemiological studies that analyze the association between UPF consumption and health outcomes, suggesting the need for better characterization of the effects of UPF intake on human health.

Australian Consumers Are Willing to Pay for the Health Star Rating Front-of-Pack Nutrition Label

The Australia and New Zealand Ministerial Forum on Food Regulation has supported the recommendations set out in the 2019 Health Star Rating System Five Year Review Report. Specifically, the forum supported, in principle, Recommendation 9, to mandate the Health Star Rating if clear uptake targets were not achieved while the system is voluntary. Given that mandatory labelling is being considered, it is important to investigate how much consumers value the Health Star Rating in order to understand potential consumer uptake and inform industry. The aim of this study was to assess consumers' valuation of the Health Star Rating system by analysing their willingness to pay for a packaged food product with the Health Star Rating label, utilising a double-bounded dichotomous choice contingent valuation approach. The results indicate that almost two-thirds of Australian household grocery shoppers were willing to pay more for a product with the Health Star Rating, on average up to an additional 3.7% of the price of the product. However, public health nutrition benefits associated with consumers' willingness to pay more for products with the Health Star Rating is currently limited by the lack of guarantee of the systems' accuracy. Given consumer support, a well validated and comprehensive Health Star Rating labelling system can potentially improve health outcomes, cost effectiveness and reduce environmental impacts.

Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers

Understanding the drivers and dynamics of global ultra-processed food (UPF) consumption is essential, given the evidence linking these foods with adverse health outcomes. In this synthesis review, we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients (sweeteners, fats, sodium and cosmetic additives) supplied by these foods, in countries classified by income and region. Second, we review the literature on food systems and political economy factors that likely explain the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs sold worldwide, representing a transition towards a more processed global diet but with wide variations between regions and countries. As countries grow richer, higher volumes and a wider variety of UPFs are sold. Sales are highest in Australasia, North America, Europe and Latin America but growing rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialization of food systems, technological change and globalization, including growth in the market and political activities of transnational food corporations and inadequate policies to protect nutrition in these new contexts. The scale of dietary change underway, especially in highly populated middle-income countries, raises serious concern for global health.

Nutrition and packaging characteristics of toddler foods and milks in Australia

OBJECTIVE

To analyse nutritional and packaging characteristics of toddler-specific foods and milks in the Australian retail food environment to identify how such products fit within the Australian Dietary Guidelines (ADG) and the NOVA classification.

DESIGN

Cross-sectional retail audit of toddler foods and milks. On-pack product attributes were recorded. Products were categorised as (1) food or milk; (2) snack food or meal and (3) snacks sub-categorised depending on main ingredients. Products were classified as a discretionary or core food as per the ADG and level of processing according to NOVA classification.

SETTING

Supermarkets and pharmacies in Australia.

RESULTS

A total of 154 foods and thirty-two milks were identified. Eighty percentage of foods were snacks, and 60 % of foods were classified as core foods, while 85 % were ultraprocessed (UP). Per 100 g, discretionary foods provided significantly more energy, protein, total and saturated fat, carbohydrate, total sugar and Na (P < 0·001) than core foods. Total sugars were significantly higher (P < 0·001) and Na significantly lower (P < 0·001) in minimally processed foods than in UP foods. All toddler milks (n 32) were found to have higher energy, carbohydrate and total sugar levels than full-fat cow's milk per 100 ml. Claims and messages were present on 99 % of foods and all milks.

CONCLUSIONS

The majority of toddler foods available in Australia are UP snack foods and do not align with the ADG. Toddler milks, despite being UP, do align with the ADG. A strengthened regulatory approach may address this issue.

Prevalence of Product Claims and Marketing Buzzwords Found on Health Food Snack Products Does Not Relate to Nutrient Profile

Growth in the consumer health and wellness industry has led to an increase of packaged foods marketed as health food (HF) products. In consequence, a ‘health halo’ around packaged HF has arisen that influences consumers at point-of-purchase. This study compared product claims (nutrient content claims (NCC), health claims and marketing ‘buzzwords’) displayed on packaged HF snack products sold in HF stores and HF aisles in supermarkets to equivalent products sold in regular aisles (RA) of supermarkets. Product Health Star Rating (HSR), nutrient profile and price were also compared. Data were collected for 2361 products from three supermarket chains, two HF chains and one independent HF store in Sydney, Australia. Mann-Whitney U tests compared the product claims, HSR, nutrient composition and unit ($) price. HF snacks displayed significantly more product claims per product compared to RA foods (HSR ≤ 2.5), median (IQR) 5.0(4.0) versus 1.0(2) and (HSR > 2.5) 4.0(4.0) versus 3.0(4), respectively (p < 0.001). A significantly different HSR was evident between HF and RA snack products, median 2.5(0) versus 2.0(1.5), respectively (p < 0.001). HF snacks cost significantly more than RA snack foods, irrespective of product HSR (p < 0.001). These findings support the recommendation for revised labelling regulations and increased education regarding consumers food label interpretation.

Evaluating Nutrient-Based Indices against Food- and Diet-Based Indices to Assess the Health Potential of Foods: How Does the Australian Health Star Rating System Perform after Five Years?

Nutrient-based indices are commonly used to assess the health potential of individual foods for nutrition policy actions. This study aimed to evaluate the nutrient profile-informed Australian Health Star Rating (HSR), against NOVA and an index informed by the Australian Dietary Guidelines (ADGs), to determine the extent of alignment. All products displaying an HSR label in the Australian marketplace between June 2014 and June 2019 were extracted from the Mintel Global New Product Database, and classified into one of four NOVA categories, and either as an ADG five food group (FFG) food or discretionary food. Of 4451 products analysed, 76.5% were ultra-processed (UP) and 43% were discretionary. The median HSR of non-UP foods (4) was significantly higher than UP foods (3.5) (p < 0.01), and the median HSR of FFG foods (4) was significantly higher than discretionary foods (2.5) (p < 0.01). However, 73% of UP foods, and 52.8% of discretionary foods displayed an HSR ≥ 2.5. Results indicate the currently implemented HSR system is inadvertently providing a ‘health halo’ for almost ¾ of UP foods and ½ of discretionary foods displaying an HSR. Future research should investigate whether the HSR scheme can be reformed to avoid misalignment with food-and diet-based indices.