A systematic interim assessment of the Australian Government's Food and Health Dialogue

Fifty shades of partnerships: a governance typology for public private engagement in the nutrition sector

BACKGROUND

Multistakeholder collaboration has emerged as a dominant approach for engaging and mobilising non-state actors; notably embedded in the paradigm of the UN Sustainable Development Goals. Yet, considerable ambiguity and contestation surrounds the appropriate terms of public private engagement (PPE) with industry actors.

MAIN BODY

This paper seeks to conceptualise different forms of engagement with the food industry in tackling diet-related noncommunicable disease, within the context of power asymmetries across engaged stakeholders. It does so by introducing the Governance Typology for Public Private Engagement in the Nutrition Sector, a typology for government-led engagement with food industry actors across three domains: (i) the form of industry and civil society actor engagement (i.e., rules of exercising institutional power), based on the degree of participation in formal decision-making as well as participation at different stages in the policy cycle; (ii) the type of industry actors being engaged (i.e., pre-existing power attributes), based on function, size, and product portfolios for profit; and (iii) the substantive policy focus of engagement.

CONCLUSIONS

The Governance Typology for Public Private Engagement in the Nutrition Sector seeks to inform national level nutrition policy makers on good engagement practice with food industry actors and complements existing risk assessment tools. This typology has the potential to inform decision-making on public sector engagement with other industries that profit from products detrimental to human and planetary health.

Food industry perspectives on potential policies targeting unhealthy food and beverage price promotions in Australian supermarkets

Current supermarket price promotions are likely to encourage unhealthy diets, leading some governments to recently endorse restrictions on price promotions for unhealthy food and beverages. However, little is known about the likely industry response to policy action in this area. The aim of this study was to understand how potential government policies targeting food and beverage price promotions in supermarkets are perceived by food industry stakeholders in Australia. Twelve semi-structured in-depth interviews were conducted with current and former employees of major food manufacturers and food retailers as well as other industry experts with experience related to price promotion practices in the Australian supermarket setting. Data were analysed deductively based on Lewin's organisational change theories and inductively to highlight forces that might drive or restrain change.From an industry perspective, forces likely to create industry opposition to implementation of price promotion policy included: fear of losing competitive advantage; potential financial loss for food retailers and their suppliers; a perception that restrictions on price promotions for unhealthy products will not impact health; and a perception of increased financial cost to consumers. Forces perceived to drive implementation of a policy that would benefit public health included: mandatory regulation; extensive compliance monitoring; support for promoting healthy products; consumer education; and sufficient lead time and support from retailers for implementation. These forces, and the way in which they interact, need to be actively considered as part of efforts to change the healthiness of food and beverage price promotions in supermarkets.

Service provider perspectives on implementing the NSW Get Healthy at Work program

Purpose: One approach increasingly used by governments to deliver on public initiatives is to partner with private enterprise through public–private partnerships. This study is a qualitative process evaluation of an Australian state-wide workplace health programme “Get Healthy at Work” from the currently under-researched perspective of the private service providers. Methods: Semi-structured interviews were conducted with nine service providers. Interviews were transcribed and analysed inductively. Results: Service providers reported an alignment of motives and skills between the programme and their organizations as a benefit of the partnership. However, they also described misalignments: between the potential and realized value of the programme to businesses and service providers; the programme cycle and business operational processes; and the capacity building approach and businesses’ expectations of the service.Conclusions: Although several hallmarks of a well-functioning private–public partnership were evident, misalignments of process and expectations challenged sustained partnership involvement by providers. Careful consideration must be given to the ongoing management functioning of cross-sector engagement and partnering in health promotion practice in order to ensure public health goals are being met, but also that the model is mutually sustainable.

The Contribution of Foods Prepared Outside the Home to the Diets of 18- to 30-Year-Old Australians: The MYMeals Study

Young adults are the highest consumers of food prepared outside home (FOH) and gain most weight among Australian adults. One strategy to address the obesogenic food environment is menu labelling legislation whereby outlets with >20 stores in one state and >50 Australia-wide must display energy content in kJ. The aim of this study was to assess the contribution of FOH to the energy and macronutrients, saturated fat, total sugars and sodium intakes of young Australians. One thousand and one 18 to 30-year-olds (57% female) residing in Australia’s most populous state recorded all foods and beverages consumed and the location of preparation for three consecutive days using a purpose-designed smartphone application. Group means for the daily consumption of energy, percentage energy (%E) for protein, carbohydrate, total sugars, total and saturated fats, and sodium density (mg/1000 kJ) and proportions of nutrients from FOH from menu labelling and independent outlets were compared. Overall, participants consumed 42.4% of their energy intake from FOH with other nutrients ranging from 39.8% (sugars) to 47.3% (sodium). Independent outlets not required to label menus, contributed a greater percentage of energy (23.6%) than menu labelling outlets (18.7%, p < 0.001). Public health policy responses such as public education campaigns, extended menu labelling, more detailed nutrition information and reformulation targets are suggested to facilitate healthier choices.

A narrative review of regulatory governance factors that shape food and nutrition policies

Food composition, marketing restrictions, nutrition labeling, and taxation policies are recommended for preventing diet-related noncommunicable diseases. In view of the increasing but variable adoption of food policies globally, this narrative review examines the actors, regulatory frameworks, and institutional contexts that shape the development, design, and implementation of these policies. We found a diverse range of actors using various strategies, including advocacy, framing, and evidence generation to influence policy agendas. We identified diverse regulatory designs used in the formulation and implementation of the policies: command and control state regulation for taxes and menu labels, quasi-regulation for sodium reformulation, and co-regulation and industry self-regulation for food marketing policies. Quasi-regulation and industry self-regulation are critiqued for their voluntary nature, lack of independence from the industry, and absence of (or poor) monitoring and enforcement systems. The policy instrument design and implementation best practices highlighted in this review include clear policy goals and rigorous standards that are adequately monitored and enforced. Future research should examine how these combinations of regulatory governance factors influence policy outcomes.

Estimating the potential impact of Australia's reformulation programme on households' sodium purchases

BACKGROUND

On average, Australian adults consume 3500 mg sodium per day, almost twice the recommended maximum level of intake. The Australian government through the Healthy Food Partnership initiative has developed a voluntary reformulation programme with sodium targets for 27 food categories. We estimated the potential impact of this programme on household sodium purchases (mg/day per capita) and examined potential differences by income level. We also modelled and compared the effects of applying the existing UK reformulation programme targets in Australia.

METHODS

This study used 1 year of grocery purchase data (2018) from a nationally representative consumer panel of Australian households (Nielsen Homescan) that was linked with a packaged food and beverage database (FoodSwitch) that contains product-specific sodium information. Potential reductions in per capita sodium purchases were calculated and differences across income level were assessed by analysis of variance. All analyses were modelled to the Australian population in 2018.

RESULTS

A total of 7188 households were included in the analyses. The Healthy Food Partnership targets covered 4307/26 728 (16.1%) unique products, which represented 22.3% of all packaged foods purchased by Australian households in 2018. Under the scenario that food manufacturers complied completely with the targets, sodium purchases will be reduced by 50 mg/day per capita, equivalent to 3.5% of sodium currently purchased from packaged foods. Reductions will be greater in low-income households compared with high-income households (mean difference -7 mg/day, 95% CI -4 to -11 mg/day, p<0.001). If Australia had adopted the UK sodium targets, this would have covered 9927 unique products, resulting in a reduction in per capita sodium purchases by 110 mg/day.

CONCLUSION

The Healthy Food Partnership reformulation programme is estimated to result in a very small reduction to sodium purchases. There are opportunities to improve the programme considerably through greater coverage and more stringent targets.

Have we compromised too much? A critical analysis of nutrition policy in Australia 2007-2018

OBJECTIVE

A comprehensive nutrition policy containing a broad package of cross-sector and synergistic policy actions is required to attenuate the systemic drivers of poor nutrition. The current study aims to critically analyse trends in the scope of federal nutrition policy actions in Australia between 2007 and 2018 by: (1) describing the changes in nutrition policy actions, benchmarked against an international best-practice policy framework and (2) investigating how and why the scope of these policy actions have changed over time by examining the decision-making processes that led to the establishment of Australia's Healthy Food Partnership (the Partnership).

DESIGN

Qualitative case study involving documentary analysis and key-informant interviews. Australian federal government documents (n 10) were analysed against the NOURISHING framework. Key informants (n 6) were interviewed and asked about the Partnership's decision-making and establishment processes.

SETTING

Australia.

PARTICIPANTS

Executive Committee (the Partnership's governing body) and working group members.

RESULTS

From 2007 to 2018, the scope of Australian national nutrition policy has fluctuated from evidence-informed recommendations for a comprehensive policy to the mostly discrete policy actions of the Partnership. Themes of 'pragmatism and compromise', 'actor relationships and lobbying' and 'political context' were critical drivers for establishing the Partnership.

CONCLUSION

The narrowing of Australian nutrition policy reflects a response to political expediency and compromise. This political dynamic highlights a dilemma facing nutrition policy advocates: should (and if so, how) a balance be sought between the aspirational but possibly unrealistic goals, and the limited but likely deliverable outcomes during policy-making processes? These findings have relevance for developing a future comprehensive national nutrition policy.

Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review

INTRODUCTION

Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap.

METHODS

Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework.

RESULTS

We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being.

CONCLUSION

Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.

The Effects of a Supermarket-Based Intervention on the Nutritional Quality of Private-Label Foods: A Prospective Study

Private-label products, products owned by supermarkets, are a growing area of the food supply. The aim of this study was to assess the effect of an intervention that provided an Australian supermarket ('intervention supermarket') with comparative nutrition data to improve the healthiness of their private-label range. Between 2015 and 2016, the intervention supermarket received reports that ranked the nutritional quality of their products against competitors. Changes in the nutrient content (sodium, sugar, saturated fat, energy and Health Star Rating) of products from the intervention supermarket between 2015 and 2018 were compared against changes achieved for three comparators (private-label products from two other supermarkets and branded products). The intervention supermarket achieved a significantly greater reduction in the sodium content of their products relative to all three comparators, which ranged between -104 and -52 mg/100 g (all p < 0.05). Conversely, the three comparators each achieved a greater relative reduction in the sugar content of their products by between -3.5 and -1.6 g/100 g (all p < 0.05). One of the comparators also had a greater relative reduction in the saturated fat and energy content of their products compared to the intervention supermarket (both p <0.05). There were negligible differences in the Health Star Rating of products between the intervention supermarket and comparators (all p > 0.05). Providing comparative nutrition information to a supermarket may be ineffective in improving the healthiness of their private-label products, likely due to competing factors that play a role in the decision-making process behind product reformulation and product discontinuation/innovation.

Effects of product reformulation on sugar intake and health-a systematic review and meta-analysis

Context

Obesity, type 2 diabetes, and dental caries are all major public health problems in the United Kingdom and contribute substantially to healthcare costs.

Objective

A systematic review and meta-analysis was conducted to determine the effect of product reformulation measures on sugar intake and health outcomes.

Data sources

Using a combination of terms, the following databases were searched-The Cochrane Library, EMBASE, MEDLINE (Ovid), and Scopus. Additionally, multiple gray literature searches were undertaken.

Data extraction

A total of 16 studies met the inclusion criteria. There were 4 randomized controlled trials, 6 studies that modeled reformulation in a country, 5 studies that modeled a different approach of reformulation, and 1 study was both a modelling study of a different approach to reformulation and a retrospective observational study. The studies were assessed for risk of bias and overall quality of evidence was rated using the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) framework.

Results

Results from randomized controlled trials suggest that consumption of reformulated products can reduce sugar intake and body weight. The pooled estimates were -11.18% (95% confidence interval [CI], -19.95 to -2.41; P < 0.00001) for changes in percentage of sugar intake, -91.00 g/day (95%CI, -148.72 to -33.28; P< 0.00001) for changes in sugar intake in grams per day, and -1.04 kg (95%CI, -2.16 to -0.08; P= 0.0002) for changes in body weight. However, the quality of the evidence was very low. Results from the other studies suggested that reformulation can reduce sugar intake and improve health. Much of the evidence draws on modeling studies.

Conclusions

This systematic review and meta-analysis suggests that product reformulation to reduce sugar content could reduce sugar intake in individuals and thus improve population health. These findings provide an important starting point for ongoing work on sugar reformulation.

Promoting population health with public-private partnerships: Where's the evidence?

Background

Although public-private partnerships have become common in the health sector, the evidence supporting their effectiveness is limited, and when the products or services provided by the private partner are harmful to health inherent conflicts of interest may be difficult to overcome. The objective of this study is to appraise the evidence describing process or effectiveness of public-private partnerships (PPPs) that aim to promote population health, and analyse how characteristics such as independence or competing interests influence the results of their evaluation.

Methods

We carried out a systematic search of Medline and Web of Science to identify scientific reports evaluating the process or effectiveness of PPPs that aim to promote population health. Two reviewers applied inclusion criteria, extracted and evaluated study quality. We classified PPPs according to the health problem tackled, the independence of the evaluation, and the potential for competition between business interests of the private partner and health promotion activity undertaken. We classified the conclusions of the evaluation as positive (supportive/tentatively supportive) or negative (semi-critical/critical).

Results

We identified 36 studies evaluating 25 PPPs. Evaluations that were favourable to the use of PPPs in health promotion were more frequently classed as “not independent” and of poor quality. On the other hand, negative evaluations were more common when the PPP involved a private partner with a high potential for competition between the health promotion activity undertaken and their financial interests. PPPs that sought to prevent non-communicable diseases were more frequently negatively evaluated compared to PPPs tackling infectious disease or other types of health problem. Almost all of the evaluations evaluated process, with only 2 papers reporting quantitative health related outcomes.

Conclusions

There is still a lack of sound evidence supporting the effectiveness of public-private partnerships in health promotion, and the evidence base is skewed by non-independent evaluations. Public health actors should abstain from engaging in agreements with industries whose business interests have a high potential for competition with the health promotion activity undertaken.

Using regulation to limit salt intake and prevent non-communicable diseases: lessons from South Africa's experience

OBJECTIVE

To analyse the policy process for the South African regulation setting upper limits for salt in thirteen commonly consumed food categories, to inform future policy action for prevention of non-communicable diseases.

DESIGN

Semi-structured interviews (n 10) were conducted with key stakeholders from government, academia, non-governmental organisations and the food industry. Interviewees were asked about the content, context, process and actors involved in developing the regulation. Data were analysed according to Walt and Gilson's health policy analysis triangle.

SETTING

South Africa.ParticipantsKey actors and stakeholders in the policy process to develop the salt regulation.

RESULTS

The regulation was a response to research establishing the effectiveness of food supply interventions and to a shared perception that government regulation was the quickest way to address the problem of salt overconsumption. While the regulations were developed through a consultative process, food industry stakeholders perceived the consultation as inadequate. Implementation is currently underway, supported by a health promotion programme. Monitoring and enforcement were identified as the most likely challenges due to capacity constraints.

CONCLUSIONS

Comprehensive mandatory salt limits are an innovative approach to food reformulation. Factors that enabled regulation included robust scientific evidence, strong political and bureaucratic leadership, and the pragmatic use of existing regulatory instruments. The main challenges identified were disagreement over the appropriate nature and extent of food industry participation, and monitoring and enforcement challenges due to capacity constraints.

Culture, management and finances as key aspects for healthy workplace initiatives

The aim of this study was to qualitatively explore the barriers and enablers to implementing healthy workplace initiatives in a sample of workplaces based in Perth, Western Australia. In-depth interviews were conducted with representatives from 31 organizations representing small, medium and large businesses in the Perth metropolitan area which reported having healthy workplace initiatives. In total, 43 factors were mentioned as influencing the implementation of healthy workplace initiatives. Factors appearing to exert the most influence on the implementation of health promoting initiatives in this sample were culture; support from managers and staff; collaboration with industry providers; financial resources circumstances and the physical environment. These factors appeared to be mutually reinforcing and interconnected. Findings suggest there may be merit in applying an organizational development lens to the implementation of workplace health promotion initiatives as this could assist in leveraging enablers and minimizing barriers.

Monitoring the changes to the nutrient composition of fast foods following the introduction of menu labelling in New South Wales, Australia: an observational study

Objective

The present study examined the energy (kilojoule) content of Australian fast-food menu items over seven years, before and after introduction of menu board labelling, to determine the impact of the introduction of the legislation.

Design

Analysis of the median energy contents per serving and per 100g of fast-food menu items. Change in energy content of menu items across the years surveyed and differences in energy content of standard and limited-time only menu items were analysed.

Setting

Five of Australia’s largest fast food chains: Hungry Jack’s, KFC, McDonald’s, Oporto and Red Rooster.

Subjects

All standard and limited-time only menu items available at each fast-food chain, collected annually for seven years, 2009–2015.

Results

Although some fast-food chains/menu item categories had significant increases in the energy contents of their menus at some time points during the 7-year period, overall there were no significant or systematic decreases in energy following the introduction of menu labelling (P=0·19 by +17 kJ/100 g, P=0·83 by +8 kJ/serving). Limited-time only items were significantly higher in median energy content per 100 g than standard menu items (+74 kJ/100 g, P=0·002).

Conclusions

While reformulation across the entire Australian fast-food supply has the potential to positively influence population nutrient intake, the introduction of menu labelling legislation in New South Wales, Australia did not lead to reduced energy contents across the five fast-food chains. To encourage widespread reformulation by the fast-food industry and enhance the impact of labelling legislation, the government should work with industry to set targets for reformulation of nutrient content.

Contribution of Discretionary Foods and Drinks to Australian Children's Intake of Energy, Saturated Fat, Added Sugars and Salt

Interventions are required to reduce children’s consumption of discretionary foods and drinks. To intervene we need to identify appropriate discretionary choice targets. This study aimed to determine the main discretionary choice contributors to energy and key nutrient intakes in children aged 2–18 years. Secondary analyses were performed with population weighted, single 24 h dietary recall data from the 2011–2012 National Nutrition and Physical Activity Survey. Cakes, muffins, and slices; sweet biscuits; potato crisps and similar snacks; and, processed meats and sugar-sweetened drinks were relatively commonly consumed and were within the top three to five contributors to per capita energy, saturated fat, sodium, and/or added sugars. Per consumer intake identified cereal-based takeaway foods; cakes, muffins and slices; meat pies and other savoury pastries; and, processed meats as top contributors to energy, saturated fat, and sodium across most age groups. Subgroups of sugar-sweetened drinks and cakes, muffins and slices were consistently key contributors to added sugars intake. This study identified optimal targets for interventions to reduce discretionary choices intake, likely to have the biggest impact on moderating energy intake while also reducing intakes of saturated fat, sodium and/or added sugars.

Eating occasions and the contribution of foods to sodium and potassium intakes in adults

OBJECTIVE

To examine dietary Na and K intake at eating occasions in Australian adults and identify the contribution of major food sources to Na and K at different eating occasions.

DESIGN

Secondary analysis of 24 h recall diet data from the Australian Health Survey (2011-2013).

SETTING

Nationally representative survey in Australia.

SUBJECTS

Male and female Australians aged 18-84 years (n 7818).

RESULTS

Dinner contributed the greatest proportion to total daily Na intake (33 %) and K intake (35 %). Na density was highest at lunch (380 mg/MJ) and K density highest at between-meal time eating occasions (401 mg/MJ). Between-meal time eating occasions provided 20 % of daily Na intake and 26 % of daily K intake. The major food group sources of Na were different at meal times (breads and mixed dishes) compared with between-meal times (cakes, muffins, scones, cake-type desserts). The top food group sources of K at meal times were potatoes and unprocessed meat products and dishes.

CONCLUSIONS

Foods which contributed to Na and K intake differed according to eating occasion. Major food sources of Na were bread and processed foods. Major food sources of K were potatoes and meat products and dishes. Public health messages that emphasise meal-based advice and diet patterns high in vegetables, fruits and unprocessed foods may also aid reduction in dietary Na intake and increase in dietary K intake.

The Healthy Eating Agenda in Australia. Is Salt a Priority for Manufacturers?

Many nation states have endorsed and acted on the World Health Organization’s target of a 30% reduction in global salt consumption by 2025. In Australia, new government-led voluntary measures were initiated in 2009, consisting of public–private partnerships, front-of-pack labelling, and food reformulation targets (which include reduced salt). How Australia’s private sector has responded to this healthy eating agenda has been investigated in a limited way, particularly with regards to manufacturers which produce processed foods considered significant sources of sodium. In this study we asked: have Australia’s largest food manufacturers made “…positive (nutrition) changes to their product portfolios” as disclosed in their public policies, priorities, and communications? And, is salt reduction a priority for processed food manufacturers? A systematic search and critical content-analysis of grey literature published by food manufacturers was conducted. The results suggest half of the sample publically describe some salt reduction activities but the scale and efficacy of these changes is unclear from the available literature. The Australian Government’s Healthy Food Partnership could capitalise on current documented activities in salt reduction, and implement a more comprehensive healthy eating agenda moving forward. In light of the increasing rates of hypertension, population salt consumption and diet-related disease, more could be done.

Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure

Background

Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organizations, national governments and civil society, especially when compared to the attention paid to secondary and tertiary prevention regimes (i.e. those focused on provision of medical treatment and long-term clinical management). This may in part reflect that until recently the NCDs have not been deemed a priority on the overall global health agenda. Low political priority may also be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector. More fundamentally, governing determinants of risk frequently brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries.

Materials

We use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. We analyse the challenges inherent in each model, and review what is known (or not) about their impact on NCD outcomes.

Conclusion

While piecemeal efforts have been established, we argue that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. Our paper sets out an agenda to strengthen each of the three governance models. We identify reforms that will be needed to the global health architecture to govern NCD risks, including to strengthen its ability to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.

Dietary salt intake in the Australian population

Objective

To update the estimate of mean salt intake for the Australian population made by the Australian Health Survey (AHS).

Design

A secondary analysis of the data collected in a cross-sectional survey was conducted. Estimates of salt intake were made in Lithgow using the 24 h diet recall methodology employed by the AHS as well as using 24 h urine collections. The data from the Lithgow sample were age- and sex-weighted, to provide estimates of daily salt intake for the Australian population based upon (i) the diet recall data and (ii) the 24 h urine samples.

Setting

Lithgow, New South Wales, Australia.

Subjects

Individuals aged ≥20 years residing in Lithgow and listed on the 2009 federal electoral roll.

Results

Mean (95 % CI) salt intake estimated from the 24 h diet recalls was 6·4 (6·2, 6·7) g/d for the Lithgow population compared with a corresponding figure of 6·2 g/d for the Australian population derived from the AHS. The corresponding estimate of salt intake for Lithgow adults based upon the 24 h urine collections was 9·0 (8·6, 9·4) g/d. When the age- and sex-specific estimates of salt intake obtained from the 24 h urine collections in the Lithgow sample were weighted using Australian census data, estimated salt intake for the Australian population was 9·0 (8·6, 9·5) g/d. Further adjustment for non-urinary Na excretion made the best estimate of daily salt intake for both Lithgow and Australia about 9·9 g/d.

Conclusions

The dietary recall method used by the AHS likely substantially underestimated mean population salt consumption in Australia.

Comparing the Nutritional Impact of Dietary Strategies to Reduce Discretionary Choice Intake in the Australian Adult Population: A Simulation Modelling Study

Dietary strategies to reduce discretionary choice intake are commonly utilized in practice, but evidence on their relative efficacy is lacking. The aim was to compare the potential impact on nutritional intake of three strategies to reducing discretionary choices intake in the Australian adult (19-90 years) population. Dietary simulation modelling using data from the National Nutrition and Physical Activity Survey 2011-2012 was conducted (n = 9341; one 24 h dietary recall). Strategies modelled were: moderation (reduce discretionary choices by 50%, with 0%, 25% or 75% energy compensation); substitution (replace 50% of discretionary choices with core choices); reformulation (replace 50% SFA with unsaturated fats, reduce added sugars by 25%, and reduce sodium by 20%). Compared to the base case (observed) intake, modelled intakes in the moderation scenario showed: -17.3% lower energy (sensitivity analyses, 25% energy compensation -14.2%; 75% energy compensation -8.0%), -20.9% lower SFA (-17.4%; -10.5%), -43.3% lower added sugars (-41.1%; -36.7%) and 17.7% lower sodium (-14.3%; -7.5%). Substitution with a range of core items, or with fruits, vegetables and core beverages only, resulted in similar changes in energy intake (-13.5% and -15.4%), SFA (-17.7% and -20.1%), added sugars (-42.6% and -43%) and sodium (-13.7% and -16.5%), respectively. Reformulating discretionary choices had minimal impact on reducing energy intake but reduced SFA (-10.3% to -30.9%), added sugars (-9.3% to -52.9%), and alcohol (-25.0% to -49.9%) and sodium (-3.3% to -13.2%). The substitution and reformulation scenarios minimized negative changes in fiber, protein and micronutrient intakes. While each strategy has strengths and limitations, substitution of discretionary choices with core foods and beverages may optimize the nutritional impact.

The Science of Salt: A regularly updated systematic review of the implementation of salt reduction interventions (March-August 2016)

This review aims to identify, summarize, and appraise studies reporting on the implementation of salt reduction interventions that were published between March and August 2016. Overall, 40 studies were included: four studies evaluated the impact of salt reduction interventions, while 36 studies were identified as relevant to the design, assessment, and implementation of salt reduction strategies. Detailed appraisal and commentary were undertaken on the four studies that measured the impact of the interventions. Among them, different evaluation approaches were adopted; however, all demonstrated positive health outcomes relating to dietary salt reduction. Three of the four studies measured sodium in breads and provided consistent evidence that sodium reduction in breads is feasible and different intervention options are available. None of the studies were conducted in low- or lower middle-income countries, which stresses the need for more resources and research support for the implementation of salt reduction interventions in these countries.

Completeness of nutrient declarations and the average nutritional composition of pre-packaged foods in Beijing, China

Increasing consumption of pre-packaged foods is likely an important driver of diet-related diseases in China. From January 2013 it became mandatory to provide a standardised nutrient declaration on pre-packaged foods in China. We collected data on pre-packaged foods from large chain supermarkets in Beijing in 2013, examined the completeness of the nutrient declaration of core required nutrients and summarised the average nutritional composition of 14 different major food groups. We also illustrated the potential use of the data by comparing sodium levels. Photos of 14,279 pre-packaged foods were collected from 16 chain supermarkets in Beijing. Data for 11,489 products were included in the evaluation of nutrient declarations and data for 10,048 in the summary analysis of average nutritional composition. Compliant nutrient declarations were displayed by 87% of products with 88% of foods displaying data for each of energy, protein, total fat, carbohydrate and sodium. Nutrients not required by the Chinese regulation were infrequently reported: saturated fat (12%), trans fat (17%) and sugars (11%). Mean sodium levels were higher in Chinese products compared to UK products for 8 of 11 major food categories, often markedly so (e.g. 1417 mg/100 g vs. 304 mg/100 g for convenience foods). There has been substantial uptake of the recently introduced Chinese nutrition labelling regulation which should help consumers to choose healthier foods. As the comparison against corresponding data about sodium from the United Kingdom shows, the nutrient data can also be used to identify broader opportunities for improvement of the food supply.

Designing a Healthy Food Partnership: lessons from the Australian Food and Health Dialogue

Background

Poor diets are a leading cause of disease burden worldwide. In Australia, the Federal Government established the Food and Health Dialogue (the Dialogue) in 2009 to address this issue, primarily through food reformulation. We evaluated the Dialogue’s performance over its 6 years of operation and used these findings to develop recommendations for the success of the new Healthy Food Partnership.

Methods

We used information from the Dialogue website, media releases, communiqués, e-newsletters, materials released under freedom-of-information, and Parliamentary Hansard to evaluate the Dialogue’s achievements from October 2013 to November 2015, using the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework. We also engaged closely with two former Dialogue members. Our findings update a prior assessment done in October 2013.

Results

Little data is available to evaluate the Dialogue’s recent achievements, with no information about progress against milestones released since October 2013. In the last 2 years, only one additional set of sodium reduction targets (cheese) was agreed and Quick Service Restaurant foods were added as an area for action. Some activity was identified in 12 of a possible 137 (9 %) areas of action within the Dialogue’s mandate. Independent evaluation found targets were partially achieved in some food categories, with substantial variation in success between companies. No effects on the knowledge, behaviours or nutrient intake of the Australian population or evidence of impact on diet-related disease could be identified.

Conclusions

The new Healthy Food Partnership has similar goals to the Dialogue. While highly laudable and recognised globally as cost-effective, the mechanism for delivery in Australia has been woefully inadequate. Strong government leadership, adequate funding, clear targets and timelines, management of conflict of interest, comprehensive monitoring and evaluation, and a plan for responsive regulation in the event of missed milestones will be required if the new Healthy Food Partnership is to achieve its urgent public health goals.

Stakeholder insights on the planning and development of an independent benchmark standard for responsible food marketing

A mixed methods qualitative survey investigated stakeholder responses to the proposal to develop an independently defined, audited and certifiable set of benchmark standards for responsible food marketing. Its purpose was to inform the policy planning and development process. A majority of respondents were supportive of the proposal. A majority also viewed the engagement and collaboration of a broad base of stakeholders in its planning and development as potentially beneficial. Positive responses were associated with views that policy controls can and should be extended to include all form of marketing, that obesity and non-communicable diseases prevention and control was a shared responsibility and an urgent policy priority and prior experience of independent standardisation as a policy lever for good practice. Strong policy leadership, demonstrable utilisation of the evidence base in its development and deployment and a conceptually clear communications plan were identified as priority targets for future policy planning. Future research priorities include generating more evidence on the feasibility of developing an effective community of practice and theory of change, the strengths and limitations of these and developing an evidence-based step-wise communications strategy.

Dietary Salt Intake and Discretionary Salt Use in Two General Population Samples in Australia: 2011 and 2014

The limited Australian measures to reduce population sodium intake through national initiatives targeting sodium in the food supply have not been evaluated. The aim was, thus, to assess if there has been a change in salt intake and discretionary salt use between 2011 and 2014 in the state of Victoria, Australia. Adults drawn from a population sample provided 24 h urine collections and reported discretionary salt use in 2011 and 2014. The final sample included 307 subjects who participated in both surveys, 291 who participated in 2011 only, and 135 subjects who participated in 2014 only. Analysis included adjustment for age, gender, metropolitan area, weekend collection and participation in both surveys, where appropriate. In 2011, 598 participants: 53% female, age 57.1(12.0)(SD) years and in 2014, 442 participants: 53% female, age 61.2(10.7) years provided valid urine collections, with no difference in the mean urinary salt excretion between 2011: 7.9 (7.6, 8.2) (95% CI) g/salt/day and 2014: 7.8 (7.5, 8.1) g/salt/day (p = 0.589), and no difference in discretionary salt use: 35% (2011) and 36% (2014) reported adding salt sometimes or often/always at the table (p = 0.76). Those that sometimes or often/always added salt at the table and when cooking had 0.7 (0.7, 0.8) g/salt/day (p = 0.0016) higher salt excretion. There is no indication over this 3-year period that national salt reduction initiatives targeting the food supply have resulted in a population reduction in salt intake. More concerted efforts are required to reduce the salt content of manufactured foods, together with a consumer education campaign targeting the use of discretionary salt.

Variations in serving sizes of Australian snack foods and confectionery

This study examined the serving size and energy content per serving of Australian packaged snack foods and confectionery products. Nutrition Information Panel data for 23 sub-categories of packaged snack foods (n = 3481) were extracted from The George Institute for Global Health's 2013 branded food composition database. Variations in serving size and energy content per serving were examined. Energy contents per serving were compared to recommendations in the Australian Dietary Guidelines. Serving sizes varied within and between snack food categories. Mean energy content per serving varied from 320 kJ to 899 kJ. More energy per serving than the recommended 600 kJ was displayed by 22% (n = 539) of snack foods classified in the Australian Dietary Guidelines as discretionary foods. The recommendation for energy content per serving was exceeded in 60% (n = 635) of snack foods from the Five Food Groups. Only 37% (n = 377) of confectionery products displayed the industry-agreed serving size of 25 g. Energy content per serving of many packaged snack foods do not align with the Australian Dietary Guidelines and the industry agreed serving size has not been taken up widely within the confectionery category. Given the inconsistencies in serving sizes, featuring serving size in front-of-pack information may hinder the objective of a clear and simple nutrition message. Messaging to help consumers make healthier choices should consider the variation in serving sizes on packaged snack foods.

Government action on diabetes prevention: time to try something new

Type 2 diabetes mellitus, driven by overweight and obesity linked to unhealthy diets, is the fastest-growing non-communicable disease in Australia. Halting the rise of diabetes will require a paradigm shift from personal to shared responsibility, with greater accountability from Australian governments and the food industry. It will also require governments to try something different to the prevailing approaches emphasising education and the provision of information. We propose four priority areas where government regulation could strengthen Australia's response. Those areas relate to mandatory front-of-pack food labelling, regulating junk food advertising, better oversight of food reformulation and taxing sugar-sweetened beverages.

A proposed approach to systematically identify and monitor the corporate political activity of the food industry with respect to public health using publicly available information

Unhealthy diets represent one of the major risk factors for non-communicable diseases. There is currently a risk that the political influence of the food industry results in public health policies that do not adequately balance public and commercial interests. This paper aims to develop a framework for categorizing the corporate political activity of the food industry with respect to public health and proposes an approach to systematically identify and monitor it. The proposed framework includes six strategies used by the food industry to influence public health policies and outcomes: information and messaging; financial incentive; constituency building; legal; policy substitution; opposition fragmentation and destabilization. The corporate political activity of the food industry could be identified and monitored through publicly available data sourced from the industry itself, governments, the media and other sources. Steps for country-level monitoring include identification of key food industry actors and related sources of information, followed by systematic data collection and analysis of relevant documents, using the proposed framework as a basis for classification of results. The proposed monitoring approach should be pilot tested in different countries as part of efforts to increase the transparency and accountability of the food industry. This approach has the potential to help redress any imbalance of interests and thereby contribute to the prevention and control of non-communicable diseases.

Food Reformulation, Responsive Regulation, and "Regulatory Scaffolding": Strengthening Performance of Salt Reduction Programs in Australia and the United Kingdom

Strategies to reduce excess salt consumption play an important role in preventing cardiovascular disease, which is the largest contributor to global mortality from non-communicable diseases. In many countries, voluntary food reformulation programs seek to reduce salt levels across selected product categories, guided by aspirational targets to be achieved progressively over time. This paper evaluates the industry-led salt reduction programs that operate in the United Kingdom and Australia. Drawing on theoretical concepts from the field of regulatory studies, we propose a step-wise or “responsive” approach that introduces regulatory “scaffolds” to progressively increase levels of government oversight and control in response to industry inaction or under-performance. Our model makes full use of the food industry’s willingness to reduce salt levels in products to meet reformulation targets, but recognizes that governments remain accountable for addressing major diet-related health risks. Creative regulatory strategies can assist governments to fulfill their public health obligations, including in circumstances where there are political barriers to direct, statutory regulation of the food industry.

Strengthening of accountability systems to create healthy food environments and reduce global obesity

To achieve WHO's target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifies multiple levers for change, including quasiregulatory and other approaches that involve government-specified and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of conflicts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the influence of private sector actors with major conflicts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives.

Salt reduction in Australia: from advocacy to action

BACKGROUND

As part of its endorsement of the World Health Organization's Global Action Plan to prevent non-communicable diseases, the Federal Government of Australia has committed to a 30% reduction in average population salt intake by 2025. Currently, mean daily salt intake levels are 8-9 g, varying by sex, region and population group. A number of salt reduction initiatives have been established over the last decade, but key elements for a co-ordinated population-level strategy are still missing. The objective of this review is to provide a comprehensive overview of existing population-level salt reduction activities in Australia and identify opportunities for further action.

METHODS

A review of the published literature and stakeholder activities was undertaken to identify and document current activities. The activities were then assessed against a pre-defined framework for salt reduction strategies.

RESULTS

A range of initiatives were identified from the review. The Australian Division of World Action on Salt and Health (AWASH) was established in 2005 and in 2007 launched its Drop the Salt! Campaign. This united non-governmental organisations (NGOs), health and medical and food industry organisations in a co-ordinated advocacy effort to encourage government to develop a national strategy to reduce salt. Subsequently, in 2010 the Federal Government launched its Food and Health Dialogue (FHD) with a remit to improve the health of the food supply in Australia through voluntary partnerships with food industry, government and non-government public health organisations. The focus of the FHD to date has been on voluntary reformulation of foods, primarily through salt reduction targets. More recently, in December 2014, the government's Health Star Rating system was launched. This front of pack labelling scheme uses stars to highlight the nutritional profile of packaged foods. Both government initiatives have clear targets or criteria for industry to meet, however, both are voluntary and the extent of industry uptake is not yet clear. There is also no parallel public awareness campaign to try and influence consumer behaviour relating to salt and no agreed mechanism for monitoring national changes in salt intake. The Victorian Health Promotion Foundation (VicHealth) has recently instigated a State-level partnership to advance action and will launch its strategy in 2015.

CONCLUSIONS

In conclusion, salt reduction activities are currently being implemented through a variety of different programs but additional efforts and more robust national monitoring mechanisms are required to ensure that Australia is on track to achieve the proposed 30% reduction in salt intake within the next decade.

The relevance of the public-private partnership paradigm to the prevention of diet-associated non-communicable diseases in wealthy countries

The public-private partnership (PPP) paradigm emerged as a form of global health governance in the mid-1990s to overcome state and market failures constraining access to essential medicines among populations with limited purchasing power in low- and middle-income countries. PPPs are now ubiquitous across the development spectrum. Yet while the narrative that the private sector must be engaged if complex health challenges are to be overcome is now dominant in development discourse, it does not yet appear to be shaping government approaches to addressing health inequalities within high-income welfare states such as Canada. This is significant as both the actions and inactions of firms factor heavily into why low-income Canadians face a disproportionate risk of developing diet-associated chronic diseases, such as type II diabetes. In the same ways PPPs have been an effective policy tool for strengthening public health in poor countries, this paper illuminates how the PPP model may have utility for mitigating poverty-associated food insecurity giving rise to diet-associated non-communicable diseases within the context of wealthy states.

An evaluation of the effects of the Australian Food and Health Dialogue targets on the sodium content of bread, breakfast cereals and processed meats

The Australian Food and Health Dialogue set sodium reduction targets for three food categories (breads, ready-to-eat breakfast cereals and processed meats) to be achieved by December, 2013. Sodium levels for 1849 relevant packaged foods on the shelves of Australian supermarkets between 2010 and 2013 were examined. Changes in mean sodium content were assessed by linear mixed models, and the significance of differences in the proportion of products meeting targets was determined using chi-squared or McNemar's tests. The mean sodium level of bread products fell from 454 to 415 mg/100 g (9% lower, p < 0.001), and the proportion reaching target rose from 42% to 67% (p < 0.005). The mean sodium content of breakfast cereals also fell substantially from 316 to 237 mg/100 g (25% lower, p < 0.001) over the study period. The decline in mean sodium content of bacon/ham/cured meats from 1215 to 1114 mg/100 g (8% lower, p = 0.001) was smaller, but associated with a rise in the proportion meeting the target from 28% to 47%. Declines in mean sodium content did not appreciably differ between companies that did and did not make public commitments to the targets. These data show that the Australian food industry can reduce salt levels of processed foods and provide a strong case for broadening and strengthening of the Food and Health Dialogue (FHD) process.

To legislate or not to legislate? A comparison of the UK and South African approaches to the development and implementation of salt reduction programs

The World Health Organization promotes salt reduction as a best-buy strategy to reduce chronic diseases, and Member States have agreed to a 30% reduction target in mean population salt intake by 2025. Whilst the UK has made the most progress on salt reduction, South Africa was the first country to pass legislation for salt levels in a range of processed foods. This paper compares the process of developing salt reduction strategies in both countries and highlights lessons for other countries. Like the UK, the benefits of salt reduction were being debated in South Africa long before it became a policy priority. Whilst salt reduction was gaining a higher profile internationally, undoubtedly, local research to produce context-specific, domestic costs and outcome indicators for South Africa was crucial in influencing the decision to legislate. In the UK, strong government leadership and extensive advocacy activities initiated in the early 2000s have helped drive the voluntary uptake of salt targets by the food industry. It is too early to say which strategy will be most effective regarding reductions in population-level blood pressure. Robust monitoring and transparent mechanisms for holding the industry accountable will be key to continued progress in each of the countries.

The association of knowledge, attitudes and behaviours related to salt with 24-hour urinary sodium excretion

AIM

Salt reduction efforts usually have a strong focus on consumer education. Understanding the association between salt consumption levels and knowledge, attitudes and behaviours towards salt should provide insight into the likely effectiveness of education-based programs.

METHODS

A single 24-hour urine sample and a questionnaire describing knowledge, attitudes and behaviours was obtained from 306 randomly selected participants and 113 volunteers from a regional town in Australia.

RESULTS

Mean age of all participants was 55 years (range 20-88), 55% were women and mean 24-hour urinary salt excretion was 8.8(3.6) g/d. There was no difference in salt excretion between the randomly selected and volunteer sample. Virtually all participants (95%) identified that a diet high in salt can cause serious health problems with the majority of participants (81%) linking a high salt diet to raised blood pressure. There was no difference in salt excretion between those who did 8.7(2.1) g/d and did not 7.5(3.3) g/d identify that a diet high in salt causes high blood pressure (p=0.1). Nor was there a difference between individuals who believed they consumed "too much" 8.9(3.3) g/d "just the right amount" 8.4(2.6) g/d or "too little salt" 9.1(3.7) g/d (p=0.2). Likewise, individuals who indicated that lowering their salt intake was important 8.5(2.9) g/d vs. not important 8.8(2.4) g/d did not have different consumption levels (p=0.4).

CONCLUSION

The absence of a clear association between knowledge, attitudes and behaviours towards salt and actual salt consumption suggests that interventions focused on knowledge, attitudes and behaviours alone may be of limited efficacy.