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Keaney M, Maganja D, Barrett E, Pettigrew S, Jones A. Selective industry adoption of a voluntary front-of-pack nutrition label results in low and skewed uptake: 10-year results for the Health Star Rating. Eur J Clin Nutr 2024:10.1038/s41430-024-01480-2. [PMID: 39103545 DOI: 10.1038/s41430-024-01480-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 07/15/2024] [Accepted: 07/19/2024] [Indexed: 08/07/2024]
Abstract
Front-of-pack nutrition labelling (FOPNL) on packaged foods is recommended by the World Health Organization to promote healthier diets. Our aim was to assess uptake of Australia's FOPNL, the Health Star Rating (HSR), overall and by HSR score received (0.5 (less healthy) to 5.0 (more healthy) in 0.5 increments) after ten years of voluntary implementation. In a sample of 21,197 products, we found HSR uptake of 37% overall in 2023. Uptake was unevenly distributed, with 24% of products with an HSR ≤ 3 displaying the label, compared to 53% of products scoring ≥3.5 (p < 0.001). Low HSR uptake on poorly rated products demonstrates that most food manufacturers will only display FOPNL where marketing value exists in a voluntary system. Poor and uneven HSR uptake limits consumers' ability to meaningfully use the label to compare and choose healthier products. Government action is urgently required to make the HSR system mandatory.
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Affiliation(s)
- Mariel Keaney
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia.
| | - Damian Maganja
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Eden Barrett
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
- School of Health Sciences, Faculty of Medicine and Health UNSW, Sydney, NSW, Australia
| | - Simone Pettigrew
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Alexandra Jones
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
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2
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Barrett EM, Pettigrew S, Neal B, Rayner M, Coyle DH, Jones A, Maganja D, Gaines A, Mozaffarian D, Taylor F, Ghammachi N, Wu JHY. Modifying the Health Star Rating nutrient profiling algorithm to account for ultra-processing. Nutr Diet 2024. [PMID: 38984976 DOI: 10.1111/1747-0080.12892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/08/2024] [Accepted: 05/19/2024] [Indexed: 07/11/2024]
Abstract
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.
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Affiliation(s)
- Eden M Barrett
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Friedman School of Nutrition Science & Policy, Food is Medicine Institute, Tufts University, Boston, Massachusetts, USA
| | - Simone Pettigrew
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mike Rayner
- Oxford Martin Programme on the Future of Food and Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Daisy H Coyle
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Alexandra Jones
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Damian Maganja
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Allison Gaines
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science & Policy, Food is Medicine Institute, Tufts University, Boston, Massachusetts, USA
- Tufts School of Medicine and Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Fraser Taylor
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Nadine Ghammachi
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jason H Y Wu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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Gümüş AB, Açık M, Durmaz SE. Health Star Rating of Nonalcoholic, Packaged, and Ready-to-Drink Beverages in Türkiye: A Decision Tree Model Study. Prev Nutr Food Sci 2024; 29:199-209. [PMID: 38974584 PMCID: PMC11223921 DOI: 10.3746/pnf.2024.29.2.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 07/09/2024] Open
Abstract
This study aimed to compare the nutritional quality of beverages sold in Türkiye according to their labeling profiles. A total of 304 nonalcoholic beverages sold in supermarkets and online markets with the highest market capacity in Türkiye were included. Milk and dairy products, sports drinks, and beverages for children were excluded. The health star rating (HSR) was used to assess the nutritional quality of beverages. The nutritional quality of beverages was evaluated using a decision tree model according to the HSR score based on the variables presented on the beverage label. Moreover, confusion matrix tests were used to test the model's accuracy. The mean HSR score of beverages was 2.6±1.9, of which 30.2% were in the healthy category (HSR≥3.5). Fermented and 100% fruit juice beverages had the highest mean HSR scores. According to the decision tree model of the training set, the predictors of HSR quality score, in order of importance, were as follows: added sugar (46%), sweetener (28%), additives (19%), fructose-glucose syrup (4%), and caffeine (3%). In the test set, the accuracy rate and F1 score were 0.90 and 0.82, respectively, suggesting that the prediction performance of our model had the perfect fit. According to the HSR classification, most beverages were found to be unhealthy. Thus, they increase the risk of the development of obesity and other diseases because of their easy consumption. The decision tree learning algorithm could guide the population to choose healthy beverages based on their labeling information.
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Affiliation(s)
- Aylin Bayındır Gümüş
- First and Emergency Aid Program, Vocational School of Health Services, Kırıkkale University, Kırıkkale 71450, Türkiye
| | - Murat Açık
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Fırat University, Elazığ 23200, Türkiye
| | - Sevinç Eşer Durmaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Kırıkkale University, Kırıkkale 71450, Türkiye
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4
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Palu A, Santos JA, Silatolu AM, Deo A, Bell C, Waqa G, Webster J, McKenzie BL. Energy, nutrient and overall healthiness of processed packaged foods in Fiji, a comparison between 2018 and 2020. BMC Public Health 2024; 24:1383. [PMID: 38783234 PMCID: PMC11112809 DOI: 10.1186/s12889-024-18787-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
In Fiji, packaged foods are becoming increasingly available. However, it is unknown if nutrition composition of these foods has changed. This study aims to assess changes in energy, nutrient content and healthiness of packaged foods by comparing data from five major supermarkets in Fiji in 2018 and 2020. Foods were categorised into 14 groups; nutrient composition information was extracted and healthiness assessed using Health Star Rating (HSR). Descriptive statistics and a separate matched products analysis was conducted summarising differences in nutrient content and HSR. There was limited evidence of change in the nutrient content of included products however, there was a small reduction in mean saturated fat in the snack food category (-1.0 g/100 g, 95% CI -1.6 to -0.4 g/100 g). The proportion of products considered healthy based on HSR, increased in the convenience foods category (28.4%, 95% CI 8.3 to 48.5) and decreased in non-alcoholic beverages (-35.2%, 95% CI -43.6 to -26.9). The mean HSR score increased in the fruit and vegetables category (0.1 (95% CI 0.1, 0.2)) and decreased for non-alcoholic beverages (-1.1 (-1.3, -0.9)) and the sauces, dressings, spreads, and dips category (-0.3 (-0.3, -0.2)). Strengthened monitoring of the food supply is needed to improve the healthiness of foods available.
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Affiliation(s)
- Aliyah Palu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia.
| | - Joseph Alvin Santos
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
| | - Ana Moala Silatolu
- Pacific Research Centre for the Prevention of Obesity and Non-communicable Diseases, Fiji National University, Tamavua Campus, Suva, Fiji
| | | | - Colin Bell
- Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Gade Waqa
- Pacific Research Centre for the Prevention of Obesity and Non-communicable Diseases, Fiji National University, Tamavua Campus, Suva, Fiji
| | - Jacqui Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
| | - Briar L McKenzie
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
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5
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Barrett EM, Gaines A, Coyle DH, Pettigrew S, Shahid M, Maganja D, Jones A, Rayner M, Mozaffarian D, Taylor F, Ghammachi N, Wu JHY. 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. NUTR BULL 2023; 48:523-534. [PMID: 37897130 DOI: 10.1111/nbu.12640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 10/29/2023]
Abstract
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.
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Affiliation(s)
- Eden M Barrett
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Food is Medicine Institute, Friedman School of Nutrition Science & Policy, Tufts University, Boston, Massachusetts, USA
| | - Allison Gaines
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Daisy H Coyle
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Simone Pettigrew
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Maria Shahid
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Damian Maganja
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Alexandra Jones
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dariush Mozaffarian
- Food is Medicine Institute, Friedman School of Nutrition Science & Policy, Tufts University, Boston, Massachusetts, USA
- Division of Cardiology, Tufts School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Fraser Taylor
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Nadine Ghammachi
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jason H Y Wu
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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6
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Shin S, Alqunaibet AM, Alsukait RF, Alruwaily A, Alfawaz RA, Algwizani A, Herbst CH, Shekar M, Finkelstein EA. A Randomized Controlled Study to Test Front-of-Pack (FOP) Nutrition Labels in the Kingdom of Saudi Arabia. Nutrients 2023; 15:2904. [PMID: 37447230 DOI: 10.3390/nu15132904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
One common strategy for governments to tackle the non-communicable disease (NCD) epidemic is front-of-package (FOP) nutrition labeling. The Kingdom of Saudi Arabia (KSA) is considering implementing a new FOP label that is based on either France's Nutri-Score (NS), which labels all foods (A = healthiest to E = least healthy) based on overall nutritional quality, or the Chilean warning label (WL) approach, which identifies foods to avoid based on select nutritional characteristics. Using a fully functional online grocery store, this study aimed to test these two promising FOP strategies by randomizing 656 KSA adults into one of the three versions of the store to complete a hypothetical grocery shop: no-label (control), NS, and WL. The NS was modified with a sugar percentage tag given that reducing sugar consumption is one of KSA's public health goals. We found that both modified NS labels and Chilean warning labels positively influenced food and beverage choices among KSA participants, but there were differential effects across the two labels. Relative to the control, NS improved the overall diet quality of the shopping baskets, measured by the weighted (by the number of servings) average NS point (ranging from 0, least healthy, to 55, healthiest), by 2.5 points [95% CI: 1.7, 3.4; p < 0.001], whereas results for WL were not statistically significant (0.6 points [95% CI: -0.2,1.5]). With respect to each nutritional attribute, we found that NS reduced sugar intake per serving, whereas WL was effective at decreasing energy and saturated fat intake per serving from food and beverages purchased. Our results suggest that the NS approach that identifies the healthiness of all foods using a holistic approach appears preferable if the purpose of the label is to improve overall diet quality as opposed to addressing select nutrients to avoid.
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Affiliation(s)
- Soye Shin
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| | | | - Reem F Alsukait
- Department of Community Health Sciences, King Saud University, Riyadh 11362, Saudi Arabia
- Health, Nutrition and Population Global Practice, World Bank Group, Washington, DC 20433, USA
| | | | | | | | - Christopher H Herbst
- Health, Nutrition and Population Global Practice, World Bank Group, Washington, DC 20433, USA
| | - Meera Shekar
- Health, Nutrition and Population Global Practice, World Bank Group, Washington, DC 20433, USA
| | - Eric A Finkelstein
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
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7
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Ganderats-Fuentes M, Morgan S. Front-of-Package Nutrition Labeling and Its Impact on Food Industry Practices: A Systematic Review of the Evidence. Nutrients 2023; 15:nu15112630. [PMID: 37299593 DOI: 10.3390/nu15112630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
The obesity epidemic has become a major public health concern globally, and the food supply is a significant driver of this trend. Front-of-package (FOP) labels have been implemented in many countries to encourage healthier food choices. This systematic review aimed to examine the effect of FOP label implementation on food manufacturers' practices. A comprehensive search of multiple databases was conducted following PRISMA guidelines, identifying 39 relevant articles from 1990 to 2021. The studies indicated that FOP labels conveying intuitive information influenced product reformulation, whereas those with numerical information without specific guidance had no impact on reducing unhealthy nutrients. The most common outcomes were sodium, sugar, and calorie reduction. Mandatory policies reported higher and more consistent effects on product reformulation compared to voluntary approaches. Voluntary FOP labeling resulted in low uptake and tended to be applied to healthier products. Food manufacturers responded to FOP labeling heterogeneously, depending on the label design and type of enforcement. FOP label implementation can reduce nutrients of concern but food manufacturers behave strategically by labeling healthier choices. This review provides recommendations for maximizing the benefits of using FOP labels to prevent obesity, and findings can inform future public health research and policymaking.
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Affiliation(s)
| | - Sherry Morgan
- Holman Biotech Commons, University of Pennsylvania, Philadelphia, PA 19104, USA
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8
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The influence of health star rating labels on plant-based foods: the moderating role of consumers’ believability. Food Qual Prefer 2023. [DOI: 10.1016/j.foodqual.2023.104827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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9
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O’Hearn M, Erndt-Marino J, Gerber S, Lauren BN, Economos C, Wong JB, Blumberg JB, Mozaffarian D. Validation of Food Compass with a healthy diet, cardiometabolic health, and mortality among U.S. adults, 1999-2018. Nat Commun 2022; 13:7066. [PMID: 36414619 PMCID: PMC9681774 DOI: 10.1038/s41467-022-34195-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/14/2022] [Indexed: 11/23/2022] Open
Abstract
The Food Compass is a nutrient profiling system (NPS) to characterize the healthfulness of diverse foods, beverages and meals. In a nationally representative cohort of 47,999 U.S. adults, we validated a person's individual Food Compass Score (i.FCS), ranging from 1 (least healthful) to 100 (most healthful) based on cumulative scores of items consumed, against: (a) the Healthy Eating Index (HEI) 2015; (b) clinical risk factors and health conditions; and (c) all-cause mortality. Nationally, the mean (SD) of i.FCS was 35.5 (10.9). i.FCS correlated highly with HEI-2015 (R = 0.81). After multivariable-adjustment, each one SD (10.9 point) higher i.FCS associated with more favorable BMI (-0.60 kg/m2 [-0.70,-0.51]), systolic blood pressure (-0.69 mmHg [-0.91,-0.48]), diastolic blood pressure (-0.49 mmHg [-0.66,-0.32]), LDL-C (-2.01 mg/dl [-2.63,-1.40]), HDL-C (1.65 mg/d [1.44,1.85]), HbA1c (-0.02% [-0.03,-0.01]), and fasting plasma glucose (-0.44 mg/dL [-0.74,-0.15]); lower prevalence of metabolic syndrome (OR = 0.85 [0.82,0.88]), CVD (0.92 [0.88,0.96]), cancer (0.95 [0.91,0.99]), and lung disease (0.92 [0.88,0.96]); and higher prevalence of optimal cardiometabolic health (1.24 [1.16,1.32]). i.FCS also associated with lower all-cause mortality (HR = 0.93 [0.89,0.96]). Findings were similar by age, sex, race/ethnicity, education, income, and BMI. These findings support validity of Food Compass as a tool to guide public health and private sector strategies to identify and encourage healthier eating.
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Affiliation(s)
- Meghan O’Hearn
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | | | - Suzannah Gerber
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - Brianna N. Lauren
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - Christina Economos
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - John B. Wong
- grid.67033.310000 0000 8934 4045Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA ,grid.67033.310000 0000 8934 4045Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA USA
| | - Jeffrey B. Blumberg
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - Dariush Mozaffarian
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA ,grid.67033.310000 0000 8934 4045Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA
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10
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Ngqangashe Y, Friel S. Regulatory governance pathways to improve the efficacy of Australian food policies. Aust N Z J Public Health 2022; 46:710-715. [PMID: 36047854 DOI: 10.1111/1753-6405.13284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 05/01/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Effective regulatory governance, which entails the actors, processes and contexts within which policies are developed, designed and implemented, is crucial for food policies to improve food environments, consumer behaviour and diet-related health. OBJECTIVE To critically assess Australian food policies for the presence of necessary and sufficient regulatory governance conditions that have been shown to effect positive nutrition outcomes from food policies. METHODS We assessed the Australian National Association of Advertisers (AANA) Food and Beverage Advertising Code, Health Star Rating Front of Pack labelling system and Sodium reformulation under the Healthy Food Partnership (HFP). The policies were analysed for the presence/absence of five regulatory governance conditions - the extent of industry involvement, regulatory design, instrument design, monitoring and enforcement. RESULTS All three policies lack one or more regulatory governance conditions crucial for policy success. Each policy has high industry involvement, an absence of government-led policy-making underpinned by legislation and lacks comprehensive enforcement. Except for the Health Star Rating system, the policies did not have comprehensive monitoring - a necessary condition for policy success. PUBLIC HEALTH IMPLICATIONS The efficacy of these three policies can be enhanced by minimising industry involvement, improving government oversight and improving monitoring systems.
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Affiliation(s)
- Yandisa Ngqangashe
- Menzies Centre for Health Governance, School of Regulation and Global governance, Australian National University, Australian Capital Territory
| | - Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global governance, Australian National University, Australian Capital Territory
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11
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Hammond D, Vanderlee L, White CM, Acton RB, White M, Roberto CA, Cameron A, Sacks G, Kirkpatrick S, Dubin J, Adams J, Jauregui A, Thrasher JF. The Conceptual Framework for the International Food Policy Study: Evaluating the Population-Level Impact of Food Policy. J Nutr 2022; 152:1S-12S. [PMID: 35274695 PMCID: PMC9188864 DOI: 10.1093/jn/nxac042] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/16/2022] [Accepted: 02/20/2022] [Indexed: 11/14/2022] Open
Abstract
An unhealthy diet is among the leading global causes of death and disability. Globally, a range of policies are being implemented to support healthy food choices at a population level, including novel polices in the areas of food marketing, nutrition labeling, and taxation of less healthy foods. There is a need to evaluate and inform the implementation of these policies, including their impacts on marginalized population subgroups. The International Food Policy Study (IFPS) consists of repeated cross-sectional surveys conducted in 5 high- and upper-middle-income countries: Australia, Canada, Mexico, the United Kingdom, and the United States. In each country, approximately 4000 adults and 1200 children and youth (aged 10-17) were recruited from a global commercial panel to complete an online survey using consistent measures and methodologies across countries. The first annual IFPS surveys were conducted in 2017 with adults; annual surveys for young people aged 10-17 were launched in 2019 in the same countries, as well as in Chile. The design of the IFPS surveys creates a framework for evaluating "natural experiments" in food policies, including comparisons over time within countries implementing the policy and comparisons with countries in which the policy was not implemented. IFPS surveys have 3 primary areas of focus: 1) knowledge, attitudes, and beliefs associated with specific policies; 2) diet-related behaviors; and 3) dietary intake, including 24-hour dietary recalls for adults in 4 of the 5 countries. Surveys also assess food insecurity, income adequacy, sex and gender, race/ethnicity, and a range of other measures to assess trends among priority subgroups. Overall, the IFPS project has the potential to address important gaps in national monitoring surveys for dietary patterns, and to evaluate the impacts of novel food policies implemented in any of the 5 countries over the study period.
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Affiliation(s)
| | - Lana Vanderlee
- École de Nutrition, Centre Nutrition, santé et société (Centre NUTRISS), and Institut sur la nutrition et les aliments fonctionnels (INAF), Université Laval, Québec, Canada
| | - Christine M White
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Rachel B Acton
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Martin White
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Christina A Roberto
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adrian Cameron
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Gary Sacks
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Sharon Kirkpatrick
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Joel Dubin
- Department Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
| | - Jean Adams
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Alejandra Jauregui
- Centre for Health and Nutrition Research, National Institute of Public Health, Cuernavaca, Mexico
| | - James F Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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12
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Cost-Benefit and Cost-Utility Analyses to Demonstrate the Potential Value-for-Money of Supermarket Shelf Tags Promoting Healthier Packaged Products in Australia. Nutrients 2022; 14:nu14091919. [PMID: 35565886 PMCID: PMC9103654 DOI: 10.3390/nu14091919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 02/01/2023] Open
Abstract
The supermarket environment impacts the healthiness of food purchased and consumed. Shelf tags that alert customers to healthier packaged products can improve the healthiness of overall purchases. This study assessed the potential value-for-money of implementing a three-year shelf tag intervention across all major supermarket chains in Australia. Cost-benefit analyses (CBA) and cost-utility analyses (CUA) were conducted based on results of a 12-week non-randomised controlled trial of a shelf tag intervention in seven Australian supermarkets. The change in energy density of all packaged foods purchased during the trial was used to estimate population-level changes in mean daily energy intake. A multi-state, multiple-cohort Markov model estimated the subsequent obesity-related health and healthcare cost outcomes over the lifetime of the 2019 Australian population. The CBA and CUA took societal and healthcare sector perspectives, respectively. The intervention was estimated to produce a mean reduction in population body weight of 1.09 kg. The net present value of the intervention was approximately AUD 17 billion (B). Over 98% of the intervention costs were borne by supermarkets. CUA findings were consistent with the CBA-the intervention was dominant, producing both health benefits and cost-savings. Shelf tags are likely to offer excellent value-for-money from societal and healthcare sector perspectives.
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Impact of front-of-pack labels on the perceived healthfulness of a sweetened fruit drink: a randomised experiment in five countries. Public Health Nutr 2022; 25:1094-1104. [PMID: 34726144 PMCID: PMC9991717 DOI: 10.1017/s1368980021004535] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Front-of-pack (FOP) nutrition labelling is a globally recommended strategy to encourage healthier food choices. We evaluated the effect of FOP labels on the perceived healthfulness of a sweetened fruit drink in an international sample of adult consumers. DESIGN Six-arm randomised controlled experiment to examine the impact of FOP labels (no label control, Guideline Daily Amounts (GDA), Multiple Traffic Lights, the Health Star Ratings (HSR), Health Warning Labels, and 'High-in' Warning Labels (HIWL)) on the perceived healthfulness of the drink. Linear regression models by country examined healthfulness perceptions on FOP nutrition labels, testing for interactions by demographic characteristics. SETTING Online survey in 2018 among participants from Australia, Canada, Mexico, United Kingdom (UK) and United States. PARTICIPANTS Adults (≥18 years, n 22 140). RESULTS Compared with control, HIWL had the greatest impact in lowering perceived healthfulness (β from -0·62 to -1·71) across all countries. The HIWL and the HSR had a similar effect in Australia. Other labels were effective in decreasing the perceived healthfulness of the drink within some countries only, but to a lower extent. The GDA did not reduce perceived healthfulness in most countries. In the UK, the effect of HIWL differed by age group, with greater impact among older participants (> 40 years). There were no other variations across key demographic characteristics. CONCLUSIONS HIWL, which communicates clear, non-quantitative messages about high levels of nutrients of concern, demonstrated the greatest efficacy to decrease the perceived healthfulness of a sweetened fruit drink across countries. This effect was similar across demographic characteristics.
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14
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Ares G, Velázquez AL, Vidal L, Curutchet MR, Varela P. The role of food packaging on children's diet: Insights for the design of comprehensive regulations to encourage healthier eating habits in childhood and beyond. Food Qual Prefer 2022. [DOI: 10.1016/j.foodqual.2021.104366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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15
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Guzman-Vilca WC, Vascones-Roman FF, Quispe-Villegas GA, Carrillo-Larco RM. High body-mass index and mortality from cardiometabolic diseases in Peru: a comparative risk assessment analysis. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17257.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: High body-mass index (BMI) is a major contributor to the global burden of cardiometabolic diseases (CMD) like type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVD). We aimed to quantify the mortality burden associated with high BMI in Peru to inform policies and set priorities. Methods: We computed population attributable fractions (PAF) combining BMI prevalence estimates from the Peruvian Demographic and Health Survey and relative risks between high BMI and CMD mortality from the GBD 2019 Study. PAFs were multiplied by the CMD deaths recorded in the national death registry to obtain the absolute number of CMD deaths attributable to high BMI in each region, sex and five-year age group. Results: In 2018, the absolute number of T2DM deaths attributable to high BMI in Peru was 1,376 (50.3%) in men and 1,663 (56.0%) in women; the absolute number of CVD deaths related to high BMI was 1,665 in men (23.6%) and 1,551 (24.7%) in women. Most CMD deaths related to high BMI were attributable to obesity class 1 and overweight. Regions with the highest proportions of CMD deaths related to high BMI were in the Amazon (Madre de Dios, Ucayali) and the Coast (Tacna, Moquegua); conversely, regions with the lowest proportions were in the Highlands (Huancavelica, Apurimac). Conclusions: High BMI is a major contributor to the CMD mortality burden in Peru, with high variability across regions. Health policies need to be strengthened to reduce BMI at the population level, which may have a subsequent reduction in the associated CMD mortality.
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A Cross-Sectional Audit of Nutrition and Health Claims on Dairy Yoghurts in Supermarkets of the Illawarra Region of New South Wales, Australia. Nutrients 2021; 13:nu13061835. [PMID: 34072130 PMCID: PMC8229526 DOI: 10.3390/nu13061835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022] Open
Abstract
Health and nutrition claims are used by consumers to guide purchasing decisions. In consequence, monitoring and evaluation of such claims to ensure they are accurate and transparent is required. The aim of this study was to investigate the use of nutrition and health claims on dairy-yoghurt products within select Australian supermarkets and assess their compliance with the revised Food Standards Code (FSC). Nutrition, health, and related claims on yoghurt products were assessed in a cross-sectional audit of five supermarkets in the Illawarra region of New South Wales. Claim prevalence, type, and compliance were assessed and products were compared against current rating measures. A total of n = 340 dairy yoghurt products were identified. Most products (97.9%) carried at least one nutrition and/or health claim, with nutrition-content claims (93.9%) the most prevalent. Most products (n = 277) met the nutrient profiling scoring criterion; while 87.9% of products did not carry the health star rating. Almost all claims surveyed (97.4%) were compliant with the FSC. Health and nutrition claims are highly prevalent across yoghurt categories, with the majority of these compliant with regulations. The ambiguity surrounding the wording and context of claims challenges researchers to investigate consumers’ interpretations of health messaging within the food environment.
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17
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Packaged food supply in Fiji: nutrient levels, compliance with sodium targets and adherence to labelling regulations. Public Health Nutr 2021; 24:4358-4368. [PMID: 34008486 DOI: 10.1017/s136898002100224x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To estimate the proportion of products meeting Fiji government labelling regulations, assess compliance with national Na reformulation targets and examine the Na and total sugar levels in packaged foods sold in selected major supermarkets. DESIGN We selected five major supermarkets in 2018 and collected the product information and nutritional content from the labels of all packaged foods sold. We organised 4278 foods into fourteen major food categories and thirty-six sub-categories and recorded the proportion of products labelled in accordance with the Fiji labelling regulations. We looked at the levels of Na and total sugar in each food category and assessed how many products complied with the Fiji reformulation targets set for Na. We also listed the companies responsible for each product. SETTING Suva, Fiji. RESULTS Fourteen percentage of packaged foods in fourteen major categories met Fiji national labelling regulations. Na was labelled on 95·4 % products, and total sugar labelled on 92·4 %. The convenience foods category had the highest Na levels (1699 mg/100 g), while confectionery had the highest content of total sugar (52·6 g/100 g). Forty percentage of eligible products did not meet the proposed voluntary Na reformulation targets. CONCLUSIONS Our findings indicate significant room for improvement in nutrient labelling, as well as a need for further enforcement of reformulation targets and monitoring of changes in food composition. Through enacting these measures and establishing additional regulations such as mandatory front-of-pack labelling, government and food industry can drive consumers towards healthier food choices and improve the nutritional quality of packaged foods in Fiji.
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18
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Rosewarne E, Chislett WK, McKenzie B, Reimers J, Jolly KA, Corben K, Trieu K, Webster J. Stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership: a qualitative study. BMC Nutr 2021; 7:12. [PMID: 33883029 PMCID: PMC8061028 DOI: 10.1186/s40795-021-00414-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/18/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Interventions to reduce population salt intake are feasible and cost-effective. The Victorian Salt Reduction Partnership implemented a complex, multi-faceted salt reduction intervention between 2014 and 2020 in the Australian state of Victoria. This study aimed to understand stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership. METHODS Semi-structured interviews were conducted with Partnership and food industry stakeholders. The Consolidated Framework for Implementation Research was adapted for the Partnership intervention and used to guide the qualitative analysis. RESULTS Fourteen Partnership and seven food industry stakeholders were interviewed. The Partnership was viewed as essential for intervention planning and decision-making and an enabler for intervention delivery. The goals of capacity building and collaborative action were perceived to have been achieved. The implementation team executed intended intervention activities and outputs, with some adaptations to strategy. Barriers and enablers to implementation were identified by interviewees, such as compatibility of individual, organisational and Partnership values and building positive relationships between the Partnership and food industry, respectively. Legal, political, social, environmental, technological and economic factors affecting intervention design, delivery and outcomes were identified. CONCLUSIONS Establishing a Partnership with diverse skills and experience facilitated collaborative action, capacity building and execution of the intervention. Monitoring and evaluating implementation informed strategy adaptations, which allowed optimisation of Partnership strategy. The importance of developing strong communication networks between strategic and implementation-levels was a key lesson.
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Affiliation(s)
- Emalie Rosewarne
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, 2006, Australia.
| | - Wai-Kwan Chislett
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, 2006, Australia
| | - Briar McKenzie
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, 2006, Australia
| | - Jenny Reimers
- Victorian Health Promotion Foundation, Melbourne, VIC, 3053, Australia
| | - Kellie-Ann Jolly
- National Heart Foundation of Australia, Melbourne, VIC, 3008, Australia
| | - Kirstan Corben
- Victorian Health Promotion Foundation, Melbourne, VIC, 3053, Australia
| | - Kathy Trieu
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, 2006, Australia
| | - Jacqui Webster
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, 2006, Australia
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19
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Pan XF, Magliano DJ, Zheng M, Shahid M, Taylor F, Julia C, Ni Mhurchu C, Pan A, Shaw JE, Neal B, Wu JHY. Seventeen-Year Associations between Diet Quality Defined by the Health Star Rating and Mortality in Australians: The Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Curr Dev Nutr 2020; 4:nzaa157. [PMID: 33204933 PMCID: PMC7649117 DOI: 10.1093/cdn/nzaa157] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Health Star Rating (HSR) is the government-endorsed front-of-pack labeling system in Australia and New Zealand. OBJECTIVES We aimed to examine prospective associations of a dietary index (DI) based on the HSR, as an indicator of overall diet quality, with all-cause and cardiovascular disease (CVD) mortality. METHODS We utilized data from the national population-based Australian Diabetes, Obesity and Lifestyle Study. The HSR-DI at baseline (1999-2000) was constructed by 1) calculation of the HSR points for individual foods in the baseline FFQ, and 2) calculation of the HSR-DI for each participant based on pooled HSR points across foods, weighted by the proportion of energy contributed by each food. Vital status was ascertained by linkage to the Australian National Death Index. Associations of HSR-DI with mortality risk were assessed by Cox proportional hazards regression. RESULTS Among 10,025 eligible participants [baseline age: 51.6 ± 14.3 y (mean ± standard deviation)] at entry, higher HSR-DI (healthier) was associated with higher consumption of healthy foods such as fruits, vegetables, and nuts, and lower consumption of discretionary foods such as processed meats and confectionery (P-trend < 0.001 for each). During a median follow-up of 16.9 y, 1682 deaths occurred with 507 CVD deaths. In multivariable models adjusted for demographic characteristics, lifestyle factors, and medical conditions, higher HSR-DI was associated with lower risk of all-cause mortality, with a hazard ratio (95% confidence interval) of 0.80 (0.69, 0.94; P-trend < 0.001) comparing the fifth with the first HSR-DI quintile. A corresponding inverse association was observed for CVD mortality (0.71; 0.54, 0.94; P-trend = 0.008). CONCLUSIONS Better diet quality as defined by the HSR-DI was associated with lower risk of all-cause and CVD mortality among Australian adults. Our findings support the use of the HSR nutrient profiling algorithm as a valid tool for guiding consumer food choices.
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Affiliation(s)
- Xiong-Fei Pan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health and State Key Laboratory of Environmental Health (incubation), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dianna J Magliano
- Diabetes and Population Health Unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Miaobing Zheng
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Victoria, Australia
| | - Maria Shahid
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Fraser Taylor
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Chantal Julia
- Sorbonne Paris Nord University, Inserm, Inrae, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Centre – University of Paris (CRESS), Bobigny, France
- Department of Public Health, Avicenne Hospital (AP-HP), Bobigny, France
| | - Cliona Ni Mhurchu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - An Pan
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health and State Key Laboratory of Environmental Health (incubation), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jonathan E Shaw
- Diabetes and Population Health Unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, Imperial College London, London, United Kingdom
| | - Jason H Y Wu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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20
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Backholer K, Sacks G, Cameron AJ. Food and Beverage Price Promotions: an Untapped Policy Target for Improving Population Diets and Health. Curr Nutr Rep 2020; 8:250-255. [PMID: 31300982 DOI: 10.1007/s13668-019-00287-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The price of foods and beverages is a critical driver of food choice, particularly among families and households with limited food budgets. Policies targeting unhealthy food and beverage price promotions represent an untapped policy target for improving population diets and health. Here we review policy options for reducing the frequency and influence of price promotions on unhealthy foods and beverages (high in one or more of salt, sugar and saturated fat), and demonstrate their potential to complement other food policies and improve population diets. RECENT FINDINGS Price promotions on unhealthy foods and beverages are ubiquitous in many settings globally and appear to be more common than price promotions for healthy food. Shoppers appear to be more responsive to price promotions on unhealthy foods and beverages compared to price promotions for healthier items, with evidence that discounts lead to impulse purchases, stockpiling and overconsumption. A range of policy options exist to reduce the influence of price promotions on unhealthy foods and beverages, but none have been tested in the real world, meaning the industry and consumer responses to such policies are unclear. Policies that reduce the prevalence and influence of unhealthy food and beverage price promotions should be considered as part of a comprehensive approach to improving population diets.
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Affiliation(s)
- Kathryn Backholer
- Global Obesity Centre (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia.
| | - Gary Sacks
- Global Obesity Centre (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
| | - Adrian J Cameron
- Global Obesity Centre (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
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21
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Gillon-Keren M, Kaufman-Shriqui V, Goldsmith R, Safra C, Shai I, Fayman G, Berry E, Tirosh A, Dicker D, Froy O, Gordon E, Chavia Ben-Yosef A, Nitsan L, Altman H, Blaychfeld-Magnazi M, Endevelt R. Development of Criteria for a Positive Front-of-Package Food Labeling: The Israeli Case. Nutrients 2020; 12:E1875. [PMID: 32585990 PMCID: PMC7353345 DOI: 10.3390/nu12061875] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/14/2020] [Accepted: 06/19/2020] [Indexed: 02/06/2023] Open
Abstract
Efforts to shape the food environment are aimed at reducing diet-related co-morbidities. Front-of-package labeling (FOPL) may support the consumers to make an informed decision at the point of purchase and encourage industry to reformulate food products. The Israeli Ministry of Health (MOH) implemented a unique FOPL system, using two colors: A mandatory warning (red) label alongside a voluntary positive (green) label. An independent Scientific Committee, from academia, the healthcare system, and MOH was appointed to determine the core principles for the positive FOPL. The criteria were based on the Mediterranean diet principles, with adjustments to the Israeli dietary habits, focusing on the health advantages of the food and considering its processing level. The food products eligible for positive FOPL are foods in their natural form or with added spices or herbs, or those that underwent minimal processing, with no food additives. Based on population consumption data, 19.8% of food products were eligible for positive FOPL; of them, 54% were fruits and vegetables, 20% dairy, and 14% grains. An evaluation plan is needed to assess the degree of acceptance of the positive FOPL by the industry, retailers, and the public, and its impact on food consumption and on public health.
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Affiliation(s)
- Michal Gillon-Keren
- Institute of Endocrinology and Diabetes, Schneider Children’s Medical Center, Petah Tikva 4920235, Israel; (M.G.-K.); (G.F.)
- Faculty of Sciences, Kibbutzim College of Education Technology and the Arts, Tel Aviv 6250769, Israel
| | - Vered Kaufman-Shriqui
- Department of Nutrition Sciences, School of Health Sciences, Ariel University, Ariel 40700, Israel;
| | - Rebecca Goldsmith
- Nutrition Division, Ministry of Health, Jerusalem 9101002, Israel; (R.G.); (C.S.); (L.N.); (H.A.); (M.B.-M.)
| | - Carmit Safra
- Nutrition Division, Ministry of Health, Jerusalem 9101002, Israel; (R.G.); (C.S.); (L.N.); (H.A.); (M.B.-M.)
| | - Iris Shai
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel;
| | - Gila Fayman
- Institute of Endocrinology and Diabetes, Schneider Children’s Medical Center, Petah Tikva 4920235, Israel; (M.G.-K.); (G.F.)
- Israeli National Council of Diabetes, Ministry of Health, Tel Aviv 6744325, Israel
| | - Elliot Berry
- Braun School of Public Health, Hebrew University-Hadassah Medical School, Jerusalem 9222507, Israel;
| | - Amir Tirosh
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan 5266202, Israel;
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Dror Dicker
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Petah Tikva 4937211, Israel
| | - Oren Froy
- The Institute of Biochemistry, Food Science and Nutrition, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot 7610001, Israel;
| | - Eli Gordon
- Food Control Services, Ministry of Health, Tel Aviv 6473912, Israel; (E.G.); (A.C.B.-Y.)
| | - Anat Chavia Ben-Yosef
- Food Control Services, Ministry of Health, Tel Aviv 6473912, Israel; (E.G.); (A.C.B.-Y.)
| | - Lesley Nitsan
- Nutrition Division, Ministry of Health, Jerusalem 9101002, Israel; (R.G.); (C.S.); (L.N.); (H.A.); (M.B.-M.)
| | - Hava Altman
- Nutrition Division, Ministry of Health, Jerusalem 9101002, Israel; (R.G.); (C.S.); (L.N.); (H.A.); (M.B.-M.)
| | - Moran Blaychfeld-Magnazi
- Nutrition Division, Ministry of Health, Jerusalem 9101002, Israel; (R.G.); (C.S.); (L.N.); (H.A.); (M.B.-M.)
| | - Ronit Endevelt
- Nutrition Division, Ministry of Health, Jerusalem 9101002, Israel; (R.G.); (C.S.); (L.N.); (H.A.); (M.B.-M.)
- School of Public Health, University of Haifa, Haifa 3498838, Israel
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22
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Abstract
PURPOSE OF REVIEW Guiding consumers toward more healthful food choices may help address the high prevalence of poor dietary quality and diet-related diseases. The use of front-of-package labels (FOPL) on food items is expanding to provide focused nutritional information or representations, often based upon nutrient profiling systems. RECENT FINDINGS FOPL provide a source of nutrition and health information that is readily understood by consumers, including those with limited literacy. There is evidence that FOPL can shift consumer behavior toward more nutritious and healthful choices. However, assessments of the effectiveness of FOPL have been restricted in scope and rely largely on simulation models rather than real-world environments. FOPL are a direct source of nutritional guidance at the point-of-purchase and provide an opportunity to convey critical information on ingredients that are associated with health promotion and/or increased risk of non-communicable diseases. However, limited evidence regarding the most effective forms of FOPL to achieve behavior change and challenges from the food industry impedes the establishment of standardized nutrient profiles and algorithms. Future opportunities for FOPL include the potential for integrating nutritional profiles with non-nutrient factors affecting health such as food processing and environmental sustainability.
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23
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Shahid M, Neal B, Jones A. Uptake of Australia's Health Star Rating System 2014-2019. Nutrients 2020; 12:E1791. [PMID: 32560224 PMCID: PMC7353262 DOI: 10.3390/nu12061791] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/12/2020] [Accepted: 06/14/2020] [Indexed: 12/18/2022] Open
Abstract
In June 2014, Australia and New Zealand adopted a voluntary front-of-pack nutrition label, the Health Star Rating (HSR) system. Our aim was to assess its uptake in Australia in the five years following adoption and examine the feasibility of proposed targets for future uptake. Numbers and proportions of products eligible to carry a HSR were recorded each year between 2014 and 2019 as part of an annual survey of four large Australian retail outlets. Uptake was projected to 2024. Mean HSR values were determined for products that were, and were not labelled with a HSR logo, and summary data presented overall, by HSR score, by major food category, by manufacturer and manufacturer group. Differences in mean HSR were assessed by independent samples t-test. HSR uptake continues to increase, appearing on 7118/17,477 (40.7%) of eligible products in 2019. Voluntary display of the HSR logo was increasing linearly at 6.8% annually. This would need to be maintained to reach 70% by 2024. Of those products displaying a HSR logo, more than three quarters (76.4%) had a HSR ≥ 3.0. Products displaying a HSR logo had a significantly higher mean HSR (3.4), compared to products not displaying a HSR logo (2.6) (p < 0.001). One hundred and thirty-nine manufacturers were using HSR, but retailers Coles, Woolworths and ALDI were together responsible for the majority of uptake (55.9%). Manufacturer members of the Australian Food and Grocery Council were responsible for 28.6% of uptake. Our findings illustrate the limits of commercial goodwill in applying HSR voluntarily. Ongoing implementation must pair clear targets and timelines for uptake with a firm pathway to make HSR mandatory if sufficient progress is not achieved.
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Affiliation(s)
- Maria Shahid
- The George Institute for Global Health, UNSW, Sydney, NSW 2042, Australia; (B.N.); (A.J.)
| | - Bruce Neal
- The George Institute for Global Health, UNSW, Sydney, NSW 2042, Australia; (B.N.); (A.J.)
- Charles Perkins Centre, University of Sydney, Sydney, NSW 2006, Australia
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Alexandra Jones
- The George Institute for Global Health, UNSW, Sydney, NSW 2042, Australia; (B.N.); (A.J.)
- Charles Perkins Centre, University of Sydney, Sydney, NSW 2006, Australia
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Nutritional Quality of Food and Beverages Offered in Supermarkets of Lima According to the Peruvian Law of Healthy Eating. Nutrients 2020; 12:nu12051508. [PMID: 32455890 PMCID: PMC7285082 DOI: 10.3390/nu12051508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 01/01/2023] Open
Abstract
The purpose of this paper was to determine the foods and beverages offered in the city of Lima, Peru, that would be subject to front-of-package warning labels (octagons) according to the thresholds for the two phases (6 and 39 months after the approval) for nutrients of concern (sugar, sodium, saturated fat, and trans-fat) included in the Peruvian Law of Healthy Eating. An observational, descriptive cross-sectional study was conducted that evaluated the nutritional composition of processed and ultra-processed foods that are sold in a supermarket chain in Lima. Of all the processed and ultra-processed foods captured, foods that report nutritional information and do not require reconstitution to be consumed were included. A descriptive analysis was carried out by food categories to report the nutrient content and the percentage of foods that would be subject to front-of-package warning labels. Results: A total of 1234 foods were evaluated, according to the initial thresholds that became effective 6 months after the law was implemented; 35.9% of foods had two octagons; 34.8% had one octagon; 15.8% had no octagons; 12% had three octagons; and no products had four octagons. At 39 months, when the final and more restrictive thresholds become effective, 4.8% did not have octagons. The majority of processed and ultra-processed foods that are sold in a Peruvian supermarket chain carry at least one octagon, and more than 10% of them carry octagons for three of the four nutrients of concern.
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The nutritional quality of supermarket own brand chilled convenience foods: an Australian cross-sectional study reveals limitations of the Health Star Rating. Public Health Nutr 2020; 23:2068-2077. [PMID: 32657266 DOI: 10.1017/s1368980020000051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the nutritional quality of Australian supermarket own brand chilled convenience foods (SOBCCF), for example, ready meals, pizza, pies and desserts. DESIGN Cross-sectional. SETTING Two large supermarkets (Coles and Woolworths) in Perth, Western Australia were audited in February 2017. PARTICIPANTS Data were extracted from photographic images of 291 SOBCCF, including front-of-pack information (i.e. product name, description and nutrition labels including Health Star Rating (HSR)) and back-of-pack information (i.e. nutrition information panel and ingredients list). SOBCCF were classified as healthy or unhealthy consistent with principles of the Australian Guide to Healthy Eating (AGTHE), NOVA classification of level of food processing and HSR score. RESULTS Fifty-four percentage of SOBCCF were classified as unhealthy according to AGTHE principles, 94 % were ultra-processed foods using NOVA and 81 % scored a HSR of ≥2·5, implying that they were a healthy choice. Some convenience food groups comprised more healthy choices overall including prepared vegetables, salad kits and bowls, soups and vegetarian food. A significantly larger proportion of SOBCCF from Coles were classified as unhealthy compared with Woolworths (70 v. 44 %, P < 0·05) using the AGTHE. CONCLUSIONS The findings suggest there is potential for Australian supermarkets to improve the nutritional quality of their SOBCCF and highlights the differences between supermarkets in applying their corporate social responsibility policies. Policies to assist consumers to select healthier foods should address difficulties in identifying healthy convenience foods. The findings reveal misclassification of unhealthy SOBCCF as healthy by the HSR suggesting that its algorithm should be reformed to align with recommendations of the AGTHE.
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Rosewarne E, Huang L, Farrand C, Coyle D, Pettigrew S, Jones A, Moore M, Webster J. Assessing the Healthy Food Partnership's Proposed Nutrient Reformulation Targets for Foods and Beverages in Australia. Nutrients 2020; 12:E1346. [PMID: 32397296 PMCID: PMC7285116 DOI: 10.3390/nu12051346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/27/2022] Open
Abstract
Non-communicable diseases (NCDs) are the leading cause of mortality and morbidity worldwide. Unhealthy diets are one of four main behavioral risk factors contributing to the majority of NCDs. To promote healthy eating and reduce dietary risks, the Australian Commonwealth Government established the Healthy Food Partnership (HFP). In 2018, the HFP consulted on proposed nutrient reformulation targets for 36 food categories to improve the overall quality of the food supply. This study assessed whether the proposed targets were feasible and appropriate. The HFP used a five-step approach to inform the proposed targets. We replicated and extended this approach using a different nutrient composition database (FoodSwitch). Products in FoodSwitch were mapped to the proposed HFP targets. The proportion of products meeting each target was calculated and the FoodSwitch data were compared with HFP data to determine whether the proposed target nutrient levels were appropriate or whether a more stringent target was feasible. Products from the FoodSwitch database (10,599) were mapped against the proposed HFP categories: 8434 products across 30 categories for sodium, 2875 products across seven categories for sugar, and 612 products across five categories for saturated fat. The analyses revealed that 14 of 30 proposed HFP targets for sodium, one of seven targets for sugar, and one of five targets for saturated fat were feasible and appropriate. For the remaining 26 reformulation targets, the results indicate that these target levels could be more stringent and alternative targets are proposed. The draft HFP targets are feasible but the majority are too conservative. If Australia is to meet its commitment to a 30 per cent reduction in the average population salt intake by 2025, these targets could be implemented as interim targets to be reached within two years. However, the opportunity exists to improve the food supply and strengthen the HFP's population health impact by adopting more ambitious and incremental targets. Reformulation programs should be prioritized and closely monitored as part of a coordinated, multi-faceted national food and nutrition strategy.
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Affiliation(s)
- Emalie Rosewarne
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW 2006, Australia; (L.H.); (C.F.); (D.C.); (S.P.); (A.J.); (M.M.); (J.W.)
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A Comparison of the Nutritional Qualities of Supermarket's Own and Regular Brands of Bread in Sweden. Nutrients 2020; 12:nu12041162. [PMID: 32331290 PMCID: PMC7230986 DOI: 10.3390/nu12041162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Devenish G, Mukhtar A, Begley A, Spencer AJ, Thomson WM, Ha D, Do L, Scott JA. Early childhood feeding practices and dental caries among Australian preschoolers. Am J Clin Nutr 2020; 111:821-828. [PMID: 32047898 DOI: 10.1093/ajcn/nqaa012] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/21/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Recent reviews have proposed a causal relationship between prolonged breastfeeding and early childhood caries (ECC), but the evidence to date is inconsistent, with few cohort studies and limited investigation of key confounders. OBJECTIVE This study aimed to investigate the relationship between dietary practices and early childhood caries in a birth cohort of Australian preschoolers. METHODS Participants underwent a standardized dental examination at 2-3 y of age to determine the prevalence of ECC (based on the presence of decayed, missing, or filled tooth surfaces). Breastfeeding practices were reported at 3, 6, 12, and 24 mo of age. Intakes of free sugars were assessed at 1 and 2 y of age. Multivariable regression models generated prevalence ratios (PR) for the association between ECC and breastfeeding duration, and between ECC and sleep feeding practices at 1 y, controlling for sociodemographic factors and free sugars intake. RESULTS There was no independent association between breastfeeding beyond 1 y of age and ECC (PR 1.42, 95% CI: 0.85, 2.38), or between breastfeeding to sleep and ECC (PR 1.12, 95% CI: 0.67, 1.88), although the direction of effect was suggestive of an association. The only factors independently associated with ECC were high free sugars intakes (PR 1.97, 95% CI: 1.13, 3.44), and greater socioeconomic disadvantage (PR 2.15, 95% CI: 1.08, 4.28). Most participants who were breastfed at 1 y of age had ceased by 18 mo or 2 y. CONCLUSIONS Breastfeeding practices were not associated with ECC. Given the wide-ranging benefits of breastfeeding, and the low prevalence of sustained breastfeeding in this study and Australia in general, recommendations to limit breastfeeding are unwarranted, and breastfeeding should be promoted in line with global and national recommendations. To reduce the prevalence of early childhood caries, improved efforts are needed to limit foods high in free sugars.
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Affiliation(s)
- Gemma Devenish
- School of Public Health, Curtin University, Perth, Australia
| | - Aqif Mukhtar
- School of Public Health, Curtin University, Perth, Australia
| | - Andrea Begley
- School of Public Health, Curtin University, Perth, Australia
| | - A John Spencer
- Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, Australia
| | - W Murray Thomson
- Department of Oral Sciences, University of Otago, Dunedin, New Zealand
| | - Diep Ha
- Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, Australia
| | - Loc Do
- Australian Research Centre for Population Oral Health, University of Adelaide, Adelaide, Australia
| | - Jane A Scott
- School of Public Health, Curtin University, Perth, Australia
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Improving Nutrition Information in the Eastern Mediterranean Region: Implementation of Front-Of-Pack Nutrition Labelling. Nutrients 2020; 12:nu12020330. [PMID: 31991939 PMCID: PMC7071186 DOI: 10.3390/nu12020330] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/10/2020] [Accepted: 01/19/2020] [Indexed: 11/22/2022] Open
Abstract
The provision of simplified nutrition information, in a prominent place on the front of food packages, is recommended as an important element of comprehensive strategies to tackle the burden of death and disease caused by unhealthy diets. There is growing evidence that front-of-pack nutrition labels are preferred by consumers, are more likely to be looked at or noticed than nutrition labelling on the back or side of packages and can help consumers to better identify healthier and less healthy products. This review summarizes current implementation of front-of-pack nutrition labelling policies in the countries of the WHO Eastern Mediterranean Region. Implementation of front-of-pack nutrition labelling in the Eastern Mediterranean Region remains limited, but three types of scheme were identified as having been implemented or at an advanced stage of development by governments in six countries. Through a review of reviews of existing research and evidence from country implementation, the authors suggest some pointers for implementation for other countries in the Region deciding to implement front-of-pack nutrition labelling policies.
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Curtain F, Locke A, Grafenauer S. Growing the Business of Whole Grain in the Australian Market: A 6-Year Impact Assessment. Nutrients 2020; 12:nu12020313. [PMID: 31991603 PMCID: PMC7071175 DOI: 10.3390/nu12020313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022] Open
Abstract
The Australia New Zealand Food Standards Code does not regulate on-pack claims describing the amount of whole grain in foods. In July 2013, The Grains & Legumes Nutrition Council™ (GLNC) established a voluntary Code of Practice for Whole Grain Ingredient Content Claims (the Code) providing guidance for whole grain claims, with cut-off values and suggested wording ≥8 g, ≥16 g, and ≥24 g per manufacturer serve (contains; high and very high in whole grain), based on a 48 g whole grain daily target intake. The aim of this impact assessment was to report the uptake of the Code by manufacturers, changes in numbers of whole grain products, and claims on-pack since 2013, including compliance. The impact assessment was undertaken in August 2019, comparing current registered manufacturers (“users”) and their products to the total number of products in the market deemed eligible for registration through GLNC product audits since 2013. Reporting included breakfast cereals, bread products, crispbreads, crackers, rice/corn cakes, rice, pasta, noodles, couscous, other grains (e.g., quinoa, buckwheat, freekeh), and grain-based muesli bars. As of 30 June 2019, there were 33 registered users and 531 registered products in Australia and New Zealand representing 43% of the eligible manufacturers and 65% of the eligible whole grain foods. Three-quarters (78% and 74%) of the eligible breakfast cereals and bread products were registered with the Code in 2019, followed by 62% of grain-based muesli bars. Only 39% of crispbread, crackers, rice/corn cakes, and rice, pasta, noodles, couscous, and other grains were registered. From 2013 there has been a 71% increase in the number of whole grain foods making claims, demonstrating strong uptake by industry, with clearer, more consistent, and compliant on-pack communication regarding whole grain content.
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Affiliation(s)
- Felicity Curtain
- Grains & Legumes Nutrition Council, Mount Street, North Sydney, Sydney 2060, Australia; (F.C.); (A.L.)
| | - Alexandra Locke
- Grains & Legumes Nutrition Council, Mount Street, North Sydney, Sydney 2060, Australia; (F.C.); (A.L.)
| | - Sara Grafenauer
- Grains & Legumes Nutrition Council, Mount Street, North Sydney, Sydney 2060, Australia; (F.C.); (A.L.)
- School of Medicine, University of Wollongong, Northfields Avenue, Wollongong 2522, Australia
- Correspondence: ; Tel.: +61-29394-8662
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Lyn R, Heath E, Dubhashi J. Global Implementation of Obesity Prevention Policies: a Review of Progress, Politics, and the Path Forward. Curr Obes Rep 2019; 8:504-516. [PMID: 31673982 DOI: 10.1007/s13679-019-00358-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW This review describes policy and regulatory strategies to prevent obesity and summarizes worldwide progress and impediments to scaling up strategies globally. RECENT FINDINGS While there is considerable variation in the breadth and depth of uptake of recommended strategies, the adoption of effective obesity prevention policies has been slow and inconsistent. There is broad consensus that strong government, corporate, and consumer actions, including regulatory measures, are needed to advance obesity prevention policies. Governments have lacked sufficient will to take necessary action, the food industry has actively worked to thwart policies to protect its commercial interests, and consumers have not exerted sufficient influence or demand to produce change. Advancing obesity prevention will require the use of effective strategies to shape and influence the information environments and political environments towards messages and actions to support public health. Greater emphasis is needed on reducing the influence of commercial interests, mobilizing civil society, and targeting vulnerable populations through equity-focused frameworks.
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Affiliation(s)
- Rodney Lyn
- School of Public Health, Georgia State University, P.O. Box 3995, Atlanta, GA, 30302-3995, USA.
| | - Erica Heath
- School of Public Health, Georgia State University, P.O. Box 3995, Atlanta, GA, 30302-3995, USA
| | - Janhavi Dubhashi
- School of Public Health, Georgia State University, P.O. Box 3995, Atlanta, GA, 30302-3995, USA
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Curtain F, Grafenauer S. Comprehensive Nutrition Review of Grain-Based Muesli Bars in Australia: An Audit of Supermarket Products. Foods 2019; 8:E370. [PMID: 31466287 PMCID: PMC6769606 DOI: 10.3390/foods8090370] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 02/04/2023] Open
Abstract
Muesli bars are consumed by 16% of children, and 7.5% of adults, and are classified as discretionary in Australian Dietary Guidelines, containing "higher fat and added sugars" compared with core food choices. This study aimed to provide a nutritional overview of grain-based muesli bars, comparing data from 2019 with 2015. An audit of muesli bars, grain-based bars, and oat slices was undertaken in January 2019 (excluding fruit, nut, nutritional supplement, and breakfast bars) from the four major supermarkets in metropolitan Sydney. Mean and standard deviation was calculated for all nutrients on-pack, including whole grain per serve and per 100g. Health Star Rating (HSR) was calculated if not included on-pack. Of all bars (n = 165), 63% were ≤ 600 kJ (268-1958 kJ), 12% were low in saturated fat, 56% were a source of dietary fibre, and none were low in sugar. Two-thirds (66%) were whole grain (≥8 g/serve), with an average of 10 g/serve, 16% of the 48 g Daily Target Intake. HSR featured on 63% of bars (average 3.2), with an overall HSR of 2.7. Compared to 2015, mean sugars declined (26.6 g to 23.7 g/100 g; p < 0.001), and 31% more bars were whole grain (109 up from 60 bars). Although categorised as discretionary, there were significant nutrient differences across grain-based muesli bars. Clearer classification within policy initiatives, including HSR, may assist consumers in choosing products high in whole grain and fibre at the supermarket shelf.
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Affiliation(s)
- Felicity Curtain
- Grains & Legumes Nutrition Council, Mount Street, North Sydney 2060, Australia.
| | - Sara Grafenauer
- Grains & Legumes Nutrition Council, Mount Street, North Sydney 2060, Australia
- School of Medicine, University of Wollongong, Northfields Avenue, Wollongong 2522, Australia
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Talati Z, Egnell M, Hercberg S, Julia C, Pettigrew S. Consumers' Perceptions of Five Front-of-Package Nutrition Labels: An Experimental Study Across 12 Countries. Nutrients 2019; 11:nu11081934. [PMID: 31426450 PMCID: PMC6723043 DOI: 10.3390/nu11081934] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/11/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
Consumers’ perceptions of five front-of-pack nutrition label formats (health star rating (HSR), multiple traffic lights (MTL), Nutri-Score, reference intakes (RI) and warning label) were assessed across 12 countries (Argentina, Australia, Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain, the UK and the USA). Perceptions assessed included liking, trust, comprehensibility, salience and desire for the label to be mandatory. A sample of 12,015 respondents completed an online survey in which they rated one of the five (randomly allocated) front-of-pack labels (FoPLs) along the perception dimensions described above. Respondents viewing the MTL provided the most favourable ratings. Perceptions of the other FoPLs were mixed or neutral. No meaningful or consistent patterns were observed in the interactions between country and FoPL type, indicating that culture was not a strong predictor of general perceptions. The overall ranking of the FoPLs differed somewhat from previous research assessing their objective performance in terms of enhancing understanding of product healthiness, in which the Nutri-Score was the clear front-runner. Respondents showed a strong preference for mandatory labelling, regardless of label condition, which is consistent with past research showing that the application of labels across all products leads to healthier choices.
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Affiliation(s)
- Zenobia Talati
- School of Psychology, Curtin University, Kent St, Bentley, WA 6102, Australia.
| | - Manon Egnell
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
| | - Serge Hercberg
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
- Public Health Departmant, Avicenne Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), 93000 Bobigny, France
| | - Chantal Julia
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
- Public Health Departmant, Avicenne Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), 93000 Bobigny, France
| | - Simone Pettigrew
- School of Psychology, Curtin University, Kent St, Bentley, WA 6102, Australia
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Riesenberg D, Backholer K, Zorbas C, Sacks G, Paix A, Marshall J, Blake MR, Bennett R, Peeters A, Cameron AJ. Price Promotions by Food Category and Product Healthiness in an Australian Supermarket Chain, 2017-2018. Am J Public Health 2019; 109:1434-1439. [PMID: 31415196 DOI: 10.2105/ajph.2019.305229] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To examine the prevalence and magnitude of price promotions in a major Australian supermarket and how they differ between core (healthy) and discretionary (less healthy) food categories.Methods. Weekly online price data (regular retail price, discount price, and promotion type) on 1579 foods were collected for 1 year (April 2017 to April 2018) from the largest Australian supermarket chain. Products audited were classified according to Australian Dietary Guidelines definitions of core and discretionary foods and according to their Health Star Rating (a government-endorsed nutrient profiling scheme).Results. On average, 15.1% (95% confidence interval [CI] = 14.7%, 15.3%) of core foods and 28.8% (95% CI = 28.6%, 29.0%) of discretionary foods were price promoted during a given week. Average discounts were -15.4% (95% CI = -16.4, -14.4) for core products and -25.9% (95% CI = -26.8, -25.1) for discretionary products. The percentage of products on price promotion and the size of the discount were larger for products with a lower Health Star Rating (P < .05).Conclusions. Price promotions were more prevalent and greater in magnitude for discretionary foods than for core foods. Policies to reduce the prevalence and magnitude of price promotions on discretionary foods could improve the healthiness of food purchased from supermarkets.
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Affiliation(s)
- Devorah Riesenberg
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Kathryn Backholer
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Christina Zorbas
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Gary Sacks
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Anna Paix
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Josephine Marshall
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Miranda R Blake
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Rebecca Bennett
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Anna Peeters
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Adrian J Cameron
- The authors are with the Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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Effect of Formulation, Labelling, and Taxation Policies on the Nutritional Quality of the Food Supply. Curr Nutr Rep 2019; 8:240-249. [DOI: 10.1007/s13668-019-00289-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Kasture A, Vandevijvere S, Robinson E, Sacks G, Swinburn B. Benchmarking the commitments related to population nutrition and obesity prevention of major food companies in New Zealand. Int J Public Health 2019; 64:1147-1157. [PMID: 31230118 DOI: 10.1007/s00038-019-01272-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/29/2019] [Accepted: 06/15/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To benchmark comprehensiveness, specificity and transparency of the nutrition-related commitments of major food companies in New Zealand. METHODS We applied the Business Impact Assessment on Obesity and Population Level Nutrition (BIA-Obesity). The largest 25 New Zealand companies in each of the packaged food (n = 15), non-alcoholic beverage (n = 2), supermarket (n = 2) and quick-service restaurant (n = 6) sectors were selected. Publicly available information on commitments was collected through an online search. Representatives from each company were asked to review and/or supplement the information collected. Commitments were then assessed, and recommendations made at the company and sector levels. RESULTS Overall scores ranged from 0 to 75% across all companies with a median score of 38%. The best-performing domain was 'corporate nutrition strategy' (median score = 55%), and the worst-performing domain was 'product accessibility' (median score = 0%). Twelve out of 25 companies fully engaged with the process. CONCLUSIONS The comprehensiveness, specificity and transparency of company commitments varied but were low overall. In the absence of strong industry commitments, government regulations, such as restrictions on unhealthy food marketing, are urgently needed. Future assessments should incorporate performance measures.
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Affiliation(s)
- Apurva Kasture
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | | | | | | | - Boyd Swinburn
- School of Population Health, The University of Auckland, Auckland, New Zealand
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Jones A, Thow AM, Ni Mhurchu C, Sacks G, Neal B. The performance and potential of the Australasian Health Star Rating system: a four‐year review using the RE‐AIM framework. Aust N Z J Public Health 2019; 43:355-365. [DOI: 10.1111/1753-6405.12908] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 12/14/2022] Open
Affiliation(s)
- Alexandra Jones
- George Institute for Global HealthUNSW Sydney New South Wales
- Charles Perkins CentreThe University of Sydney New South Wales
| | - Anne Marie Thow
- Menzies Centre for Health PolicyThe University of Sydney New South Wales
| | - Cliona Ni Mhurchu
- George Institute for Global HealthUNSW Sydney New South Wales
- National Institute for Health InnovationUniversity of Auckland New Zealand
| | - Gary Sacks
- School of Health and Social DevelopmentDeakin University Melbourne Victoria
| | - Bruce Neal
- George Institute for Global HealthUNSW Sydney New South Wales
- Department of Epidemiology and Biostatistics, School of Public HealthFaculty of Medicine, Imperial College London London United Kingdom
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Moore M, Jones A, Pollard CM, Yeatman H. Development of Australia's front-of-pack interpretative nutrition labelling Health Star Rating system: lessons for public health advocates. Aust N Z J Public Health 2019; 43:352-354. [PMID: 31141259 DOI: 10.1111/1753-6405.12906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/01/2019] [Accepted: 04/01/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To draw advocacy lessons from actions undertaken by public health groups to assist the development of Australia and New Zealand's Health Star Rating (HSR) front-of-pack nutrition labelling system. METHODS The advocacy approaches undertaken by the Public Health Association of Australia leading up to the time of the adoption of the HSR is examined using a 10 step advocacy framework. Key roles in advocacy planning and implementation are described, along with coordinating efforts by health and consumer groups during the HSR development processes. RESULTS HSR aims to support consumers to make informed choices to protect from diet-related diseases, including obesity. The HSR launched despite a number of major obstacles, owing to a strategic, coordinated advocacy effort undertaken by a guiding coalition. CONCLUSIONS Actions to improve nutrition are often highly contested, particularly if the desired outcome competes with commercial interests. However, by deploying a structured approach to public health advocacy it is possible to influence government despite opposition from commercial interests. Implications for public health: A shared vision and a coordinated effort by public health professionals enabled advocates to overcome undue commercial influence.
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Affiliation(s)
- Michael Moore
- The George Institute for Global Health, UNSW Sydney, New South Wales.,UC Health Research Institute, University of Canberra, Australian Capital Territory
| | - Alexandra Jones
- The George Institute for Global Health, UNSW Sydney, New South Wales
| | | | - Heather Yeatman
- Faculty of Social Science, University of Wollongong, New South Wales
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Niven P, Morley B, Dixon H, Martin J, Jones A, Petersen K, Wakefield M. Effects of health star labelling on the healthiness of adults' fast food meal selections: An experimental study. Appetite 2019; 136:146-153. [PMID: 30684644 DOI: 10.1016/j.appet.2019.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
The addition of Health Star Rating (HSR) labelling to menus at fast food outlets is feasible, however how this would impact consumer menu selection remains unclear. The aim of this study was to test whether the addition of HSR labelling to kilojoule (kJ) labelling on menus at fast food outlets would prompt consumers to select healthier meals. Using a between-subjects experimental design, 1007 adults aged 18-49 were allocated to one of four menu labelling conditions: (i) no labelling; (ii) kilojoule labelling; (iii) HSR labelling; and (iv) kilojoule + HSR labelling. Respondents were presented with their assigned menu online and instructed to select an evening meal as they would at a fast food restaurant. The main analyses tested differences by menu labelling condition in the total mean kilojoule content and Nutrient Profiling Score (NPS) of respondents' evening meal selections using one-way ANOVA. The mean kilojoule content of meals did not differ significantly by menu labelling condition. However, respondents in the kilojoule + HSR labelling condition selected healthier meals (lower mean NPS) than those who viewed menu boards with kilojoule labelling only (M = 2.88 cf. M = 3.78, p = 0.046). In addition, in a post hoc per-protocol analysis of respondents who reported using menu labelling to assist their meal selection, respondents shown kilojoule + HSR menu labelling selected meals with a significantly lower kilojoule content compared to those shown HSR labelling only (4751 kJ cf. 5745 kJ, p = 0.038). Findings provide evidence that adding HSRs to kilojoule labelling on menu boards at fast food outlets has the potential to assist adults to make healthier evening meal selections.
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Affiliation(s)
- Philippa Niven
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Belinda Morley
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Helen Dixon
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia.
| | - Jane Martin
- Obesity Policy Coalition, Melbourne, Victoria, Australia
| | - Alexandra Jones
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Charles Perkins Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Kristina Petersen
- The George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; The Pennsylvania State University, Department of Nutritional Sciences, University Park, PA, USA
| | - Melanie Wakefield
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
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Health Star Rating in Grain Foods-Does It Adequately Differentiate Refined and Whole Grain Foods? Nutrients 2019; 11:nu11020415. [PMID: 30781440 PMCID: PMC6412646 DOI: 10.3390/nu11020415] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/03/2019] [Accepted: 02/07/2019] [Indexed: 01/02/2023] Open
Abstract
The Australian front-of-pack labelling system, Health Star Rating (HSR), does not include whole grain (WG) in its algorithm, but uses dietary fibre (DF), despite Dietary Guidelines recommending WG over refined grain (RG) foods. This study aimed to determine how effectively HSR differentiates WG and RG foods. Product label data were collected 2017–18 from bread, rice, pasta, noodles, flour and breakfast cereals (n = 1127). Products not displaying HSR, DF per 100 g, and %WG ingredients were excluded, leaving a sample of 441 products; 68% were WG (≥8 g/manufacturer serving). There was a significant difference (p < 0.001) in HSR between WG bread and breakfast cereal over RG varieties, yet the mean difference in stars depicted on the pack was only 0.4 for bread and 0.7 for breakfast cereal. There was no difference for rice (p = 0.131) or flour (p = 0.376). Median HSR also poorly differentiated WG. More WG foods scored 4–5 stars compared to RG, yet there was notable overlap between 3.5–5 stars. DF content between RG and WG subcategories was significantly different, however wide variation and overlap in DF highlights that this may not be a sufficient proxy measure, raising concerns that the HSR algorithm may not adequately communicate the benefits for consumers of swapping to WG foods.
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Pulker CE, Trapp GSA, Scott JA, Pollard CM. Alignment of Supermarket Own Brand Foods' Front-of-Pack Nutrition Labelling with Measures of Nutritional Quality: An Australian Perspective. Nutrients 2018; 10:E1465. [PMID: 30304807 PMCID: PMC6213021 DOI: 10.3390/nu10101465] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Claire Elizabeth Pulker
- School of Public Health, Curtin University, Kent Street, GPO Box U1987, Perth 6845, Western Australia, Australia.
| | - Georgina S A Trapp
- Telethon Kids Institute, The University of Western Australia, P.O. Box 855, West Perth 6872, Western Australia, Australia.
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley 6009, Western Australia, Australia.
| | - Jane Anne Scott
- School of Public Health, Curtin University, Kent Street, GPO Box U1987, Perth 6845, Western Australia, Australia.
| | - Christina Mary Pollard
- School of Public Health, Curtin University, Kent Street, GPO Box U1987, Perth 6845, Western Australia, Australia.
- East Metropolitan Health Service, Kirkman House, 20 Murray Street, East Perth 6004, Western Australia, Australia.
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