The Impact of the Australasian 'Health Star Rating', Front-of-Pack Nutritional Label, on Consumer Choice: A Longitudinal Study

Are Front-of-Pack Nutrition Labels Influencing Food Choices and Purchases, Diet Quality, and Modeled Health Outcomes? A Narrative Review of Four Systems

Front-of-Pack Nutrition labels (FOPNLs) aim to improve consumers' food purchases and prompt product reformulation by the food and beverage industry. Despite their widespread use, the effectiveness of FOPNL in achieving these goals is still a matter of debate. This review has gathered 65 original studies exploring the performances of four widely used FOPNLs (Multiple Traffic Light, Warning signs, Nutri-Score and Health Star Rating). Although FOPNLs have been associated with healthier food purchases, the magnitude of improvements was small and dependent on study settings. Any associated health effects were modeled rather than observed. None of the four FOPNLs clearly outperformed the other ones on any outcome. Few studies dealt with the impact of FOPNL on product reformulation. Some of those studies, but not all, found small reductions in energy, sodium, sugar and saturated fat content of foods in some food categories. Although global trends point to a small favorable effect of FOPNL, this conclusion is subject to caution since the evidence is inconsistent and comes from a wide variety of contexts and study designs. There remain numerous research gaps, notably with regard to the optimal characteristics of FOPNLs, the durability of FOPNL effects on consumer behaviors, and any possible unexpected consequences.

The Relative Merits of Observational and Experimental Research: Four Key Principles for Optimising Observational Research Designs

The main barrier to the publication of observational research is a perceived inferiority to randomised designs with regard to the reliability of their conclusions. This commentary addresses this issue and makes a set of recommendations. It analyses the issue of research reliability in detail and fully describes the three sources of research unreliability (certainty, risk and uncertainty). Two of these (certainty and uncertainty) are not adequately addressed in most research texts. It establishes that randomised designs are vulnerable as observation studies to these two sources of unreliability, and are therefore not automatically superior to observational research in all research situations. Two key principles for reducing research unreliability are taken from R.A. Fisher’s early work on agricultural research. These principles and their application are described in detail. The principles are then developed into four key principles that observational researchers should follow when they are designing observational research exercises in nutrition. It notes that there is an optimal sample size for any particular research exercise that should not be exceeded. It concludes that best practice in observational research is to replicate this optimal sized observational exercise multiple times in order to establish reliability and credibility.

Plant Protein and Plant-Based Meat Alternatives: Consumer and Nutrition Professional Attitudes and Perceptions

Plant-based and flexitarian eating patterns are increasingly popular, and the food supply system has responded with a wide range of convenience products despite a lack of understanding regarding consumer views. The aim of this study was to explore consumer and nutrition professional (NP) perceptions and attitudes to plant protein, including plant-based meat alternatives (PBMA) within an Australian context. Using an online survey promoted via social media, 679 responses (89% completion rate), achieved an even spread across key age groups. A total of sixty percent reported following a special diet, with 25% vegan and 19% flexitarian. ‘Health’ was a key driver for diet type among the NPs (53.3%) and they were less likely to follow a special diet, while “ethical” reasons were cited by consumers (69%). Plant-based eating was considered a vegan dietary pattern and the most frequently consumed plant-based proteins were whole grains. Most (74%) had tried PBMA, but they were more frequently chosen by consumers, with burger patties then sausages and mince selected as a ‘trendy’ choice; taste was very important across both groups. Products mimicking chicken and fish were of less interest. Plant-based claims were observed by 78% but these were also of greater interest to consumers. Participants reported looking for whole ingredients and iron content and expected that both iron and vitamin B12 would be comparable to red meat. Sodium was the nutrient of greatest interest to NPs and, together, these results help inform the direction for product innovation, while also highlighting the need to assess the adequacy of the dietary pattern when promoting sustainable plant-based eating.

What Makes a Front-of-Pack Nutritional Labelling System Effective: The Impact of Key Design Components on Food Purchases

The relative impacts on food purchases of many alternative front-of-pack nutritional labelling systems were tested, with various methods—from opinion pool to nationwide experiments. Clearly, some systems induce better purchasing responses, having better nutritional impacts on food baskets. Nonetheless, we still ignore what the ingredients of an efficient label are. Here, we propose guidance for label designers. To do so, we first propose a typology that breaks down established labelling systems into four elementary components: Directiveness, Scope and Gradation, Set of Reference and Sign. On this basis, we then build seven alternative generic labelling systems that we test in a framed-field experiment enabling us to measure the effect of each component on food purchases in isolation. Our results show that an effective front-of-pack labelling system should be Food-Directive (instead of Diet-Directive) and be displayed on both healthy and unhealthy food. The reference set, which is across categories or within categories, produces the same average nutrition score but generates contrasting behavioural responses.

Energy Density of New Food Products Targeted to Children

High dietary energy density (ED) is linked to childhood obesity and poor diet quality. The Australian Health Star Rating (HSR) system aims to assist consumers in making healthful food choices. This cross-sectional study used 2014-2018 data from the Mintel Global New Products Database to describe the ED of new food products targeted to children (5-12 years) released after the introduction of HSR and examine relationships between ED and HSR. Products were categorised by ED (low < 630 kJ/100 g, medium 630-950 kJ/100 g, high > 950 kJ/100 g) and HSR (no, HSR < 2.5 low, HSR ≥ 2.5 high). Non-parametric statistics were used to examine ED and HSR. A total of 548 products targeted children: 21% low, 5% medium, 74% high ED. One hundred products displayed an HSR: 24% low, 76% high; 53 products with both high HSR and ED. The EDs of products differed by HSR (p < 0.05), but both group's medians (HSR < 2.5: 1850 kJ/100 g, HSR ≥ 2.5: 1507 kJ/100 g) were high. A high proportion of new products had a high ED, and the HSR of these foods did not consistently discriminate between ED levels, particularly for high ED foods. Policies to promote lower ED foods and better alignment between ED and HSR may improve childhood obesity and diet quality.

The Effect of Front-of-Pack Nutritional Labels and Back-of-Pack Tables on Dietary Quality

A healthy diet is important to prevent lifestyle diseases. Food labels have been proposed as a policy tool to improve the healthiness of food choices, as they provide information about nutritional content and health attributes which may otherwise have been unknown to the consumer. This study investigates the effect of food labels with different formats on dietary quality by using home-scan panel data and difference-in-difference methods to compare the change in dietary quality over time for households that start to use food labels with households that do not use labels. I find that the use of front-of-pack (FOP) nutritional labels increases overall dietary quality, which is driven by reduced intake of added sugar and increased intake of fiber. The use of back-of-pack (BOP) nutritional tables does not influence dietary quality. There is no additional benefit to overall dietary quality by using both labels. However, the results indicate that there could be a benefit of using both labels on certain nutrients. The results imply that additional policies are needed to supplement food labels in order to improve dietary quality.

An Experimental Comparison of the Impact of 'Warning' and 'Health Star Rating' FoP Labels on Adolescents' Choice of Breakfast Cereals in New Zealand

This research investigated the performance of the red, octagonal Vienna Convention traffic ‘STOP’ sign as a front of pack (FoP) warning nutritional label. While the Vienna Convention traffic light system is an established FoP label, the potential of the ‘STOP’ sign in the role has not been investigated. The performance of the ‘STOP’ label was compared with that of a single star (low nutritional value) Australasian Health Star Rating (HSR) label using a fractionally replicated Latin square design. The labels were presented on choice diads of cold breakfast cereal packets. The sample of 240 adolescents aged 16–18 was drawn from a secondary school in the South Island of New Zealand. A large and significant main effect was observed at the p < 0.01 level for the difference between the ’STOP’ sign and the control condition (no nutritional FoP label), and at p < 0.05 for the difference between the HSR and the ‘STOP’ label. There was no significant difference between the HSR FoP and the control condition. A significant non-additivity (interaction) (p < 0.01) was also observed via the fractional replication. The results indicate that the Vienna Convention ‘STOP’ sign is worthy of further research with regard to its potential as an FoP nutritional label.

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.

A Comparison of the Nutritional Qualities of Supermarket's Own and Regular Brands of Bread in Sweden

Processed food is associated with unhealthy qualities such as higher content of harmful fats, sugars and salt. The aim of our study was to compare the nutritional qualities of supermarket's own brands and regular brands of bread sold in Sweden. Additionally, we compared the nutritional qualities of gluten-free and gluten-containing bread. We collected information from the labels of 332 bread products available in the largest grocery store chains. The Australian Health Star Rating (HSR) system was used to quantify the nutritional quality of each bread product. We compared all supermarket's own brand products to regular brand products, and gluten-free to gluten-containing bread. The mean HSR for the supermarket's own brands was lower than the regular brands (3.6 vs. 3.7; p = 0.046). For the regular brand products, the fibre, sugar and total fat content were greater (p < 0.001, p = 0.002 and p = 0.021, respectively), while less protein (p = 0.009) compared to regular bread products. Gluten-free bread had a lower HSR than gluten-containing bread (mean 3.5 vs. 3.8, respectively; p < 0.001). The regular brand products were slightly healthier than the supermarket's own brands, primarily as a result of a higher fibre content. Gluten-free bread products were slightly unhealthier due to a lower protein content.

Alignment of Supermarket Own Brand Foods' Front-of-Pack Nutrition Labelling with Measures of Nutritional Quality: An Australian Perspective

Two voluntary front-of-pack nutrition labels (FOPNL) are present in Australia: the government-led Health Star Ratings (HSR) and food industry-led Daily Intake Guide (DIG). Australia's two largest supermarkets are key supporters of HSR, pledging uptake on all supermarket own brand foods (SOBF). This study aimed to examine prevalence of FOPNL on SOBF, and alignment with patterns of nutritional quality. Photographic audits of all SOBF present in three large supermarkets were conducted in Perth, Western Australia, in 2017. Foods were classified as nutritious or nutrient-poor based on the Australian Guide to Healthy Eating (AGTHE), NOVA level of food processing, and HSR score. Most (81.5%) SOBF featured FOPNL, with only 55.1% displaying HSR. HSR was present on 69.2% of Coles, 54.0% of Woolworths, and none of IGA SOBF. Half (51.3%) of SOBF were classified as nutritious using the AGTHE, but using NOVA, 56.9% were ultra-processed foods. Nutrient-poor and ultra-processed SOBF were more likely than nutritious foods to include HSR, yet many of these foods achieved HSR scores of 2.5 stars or above, implying they were a healthy choice. Supermarkets have a powerful position in the Australian food system, and they could do more to support healthy food selection through responsible FOPNL.