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Healthy eating’s appetite for change

As the global community deals with the twin challenges of obesity and malnutrition, experts are looking for new solutions, including working with food companies to improve their products and encouraging families to cook and eat together.

What should we eat to be healthy? A century and a half of nutrition research has delivered an abundance of insights and a variety of messages aimed at providing a useful answer.

Over the decades, people have been on the receiving end of mixed messages from researchers, government bodies, the media and the health industry: eliminate sugar, rein in carbohydrates, cut down on salt, ramp up antioxidants, eat less fat – or only good fats, not the bad ones.

On a parallel journey, the food industry has been reformulating its products and highlighting the ‘health benefits’ to consumers. ‘Health halos’ glow from familiar front-of-pack (FOP) claims that products are “low in fat”, “high in calcium”, “a source of omega-3”, “build strong bones”, “reduce cholesterol absorption” and “contains whole grains”.

In an effort to clarify this complex topic, US writer Michael Pollan, author of The Omnivore’s Dilemma, suggested in 2007 that we should “Eat food. Not too much. Mostly plants.” His simple message resonated because it cut through the complex maze of food and dietary advice. Pollan recognised that the effectiveness of dietary messages had become diluted, writing, “who wants to hear, yet again, ‘Eat more fruits and vegetables’.”

Infographic: One in three people globally suffers from malnutrition
63% of Australians are overweight or obese

Searching for solutions

Policymakers across the world are looking for ways to stem the obesity epidemic and take pressure off public health systems. In 2016, the Australian Institute of Health and Welfare reported more than 63 per cent of Australia’s population was overweight or obese.

At the same time,  public attention is shifting to whole foods and fresh foods – often called ‘real foods’ – with commentators such as Pollan leading the charge to broader approaches. In an article for The New York Times he pointed out, “Once food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket”.

The question faced by policymakers is how to transform this thinking into community-wide initiatives that not only raise awareness but also drive behavioural change.

The power of front-of-pack ratings

While governments globally engage in topline approaches such as dietary guidelines and food guides, there is a growing emphasis on capturing consumers’ attention at the purchase point. In some territories, supermarkets have emerged as a critical proving ground for messages around healthy eating, delivered via front-of-pack (FOP) nutritional labelling.

In the UK, Multiple Traffic Light labelling (MTL), which uses red, amber and green colour-coding to indicate high, medium and low amounts of certain nutrients in a product, was introduced on a voluntary basis in 2006. Versions of the MTL are also being used in Ecuador and South Korea.

In Australia, the voluntary Health Star Ratings (HSR) system was introduced in 2014. Rather than highlighting individual nutrient components in the way of MTL labelling, the HSR system offers a single metric: a rating of 0.5 to 5 stars based on an overview of the kilojoules, saturated fat, sugar, sodium, protein, fibre, and fruit and vegetable content of the product.

Infographic: The voluntary Health Star Ratings system has had a strong uptake by manufacturers

Designed as a “quick and easy way to compare the nutritional profile of packaged foods”, the system was developed in collaboration with Australian federal, state and territory governments, the food manufacturing industry, retail industry, public health organisations and consumers.

A five-year review is currently underway. However, its
two-year review, released earlier this year, shows the system has had strong uptake among Australian manufacturers, with the number of products featuring star ratings on their packaging leaping from 363 in the first year (June 2014 to June 2015) to 2031 a year later.

Unprompted awareness among Australians of HSR was 26 per cent of all consumers surveyed in June 2016, outstripping all other nutrition logos or labelling, with the exception of the Heart Foundation Tick.

HSR’s simple appeal

Professor Bruce Neal, Senior Director at The George Institute for Global Health, is an affirmed supporter of front-of-pack initiatives. He has experience with the FTL system, as one of the creators of the FoodSwitch app, launched in Australia in 2012. And he believes the HSR system is world leading “for a voluntary system”, although he has publicly found fault with its inability to distinguish between added and naturally-occurring sugars. (From 2018, US food manufacturers will have to include both total and added sugars on food labels.)

HSR’s winning appeal, Neal believes, is in cutting confusion by bringing nutritional information together as one metric. He ventures, “It makes sense to have one labelling system supporting Australians’ food choices.” He’d like it applied to fast foods.

 

Star ratings in practice

The feedback from Neal’s research has been positive, and approval for the HSR system is widespread even if its implementation is not. (Though uptake is growing, the voluntary system is currently used on just a fraction of all the packaged goods available for sale in Australian supermarkets.) VicHealth is among the systems’ supporters and would like to see it made mandatory: applied across all packaged goods, as well as fruit and vegetables.

However, the HSR system does have anomalies and some manufacturers have been called out for effectively gaming the system.

In early 2016, consumer advocacy group Choice took food manufacturers Nestle and Kellogg’s to task for ‘health washing’. In the case of Milo, Nestle used the HSR algorithm to calculate 4.5 stars for the 46 per cent sugar product by combining three teaspoons of the food-drink powder with 200mL of skim milk, not helpful for those who prefer it in full-cream milk, Choice pointed out.

Choice also highlighted how Kellogg’s displayed a 3.5 star rating on the side of packs of cereals that actually scored fewer stars, by using the 3.5 star as an example in an explanatory panel about how the ratings worked.

At present, the HSR system is not mandatory and only applies to packaged foods. As a result, some critics suggest that it may act as a trigger for consumers to substitute one packaged or processed food product with another, rather than substantially changing their dietary choices by choosing from a different, healthier category, such as fresh fruit and vegetables.

However, on a more positive note, the HSR system has been credited with driving change among food producers by serving as an incentive to reformulate products in pursuit of better ratings. The two-year progress report states, “Several companies [reported] changing product formulations in order to obtain a higher star rating. Reformulation actions include reducing sodium, sugars and saturated fat and, in some cases, increasing the content of ingredients with nutritional benefits such as fibre.”

VicHealth has also been involved in encouraging food producers to reformulate products through its work with the Victorian Salt Reduction Partnership. Learn more about how the Partnership is influencing the industry to reduce sodium levels in processed foods in the breakout story ‘State action on salt’.
Infographic: Since Hungary's sugar tax came into effect in 2001, people have reduced their consumption of sugary drinks

Exploring policy interventions

Front-of-pack labelling is not the only tactic being used to address healthy eating habits in the population. In countries such as Hungary and Mexico, early indications are that policies such as taxing sugar can have an effect on consumer choices and company behaviour.

Hungary’s sugar tax came into effect in September 2011. Since then, 22 per cent of people have dropped their energy drink consumption and 19 per cent say they have reduced their intake of sugar-sweetened soft drinks.

Research also shows Mexico’s sugar tax, which included a media campaign linking sugary beverages to diabetes and a 1 peso per litre ‘soda tax’, has worked.

Sugar taxes have now been introduced in France, Chile, a growing number of US cities, and in South Africa in April, with the UK and Ireland planning to put a duty on soft drinks in 2018. 

Calls for a sugar tax in Australia are growing louder. Modelling by University of Melbourne’s Centre for Health Policy researchers, released this year, shows taxing foods high in sugar, salt and saturated fats, as well as subsidising fruit and vegetables, could save $3.4 billion in healthcare costs.

In January 2017 the Obesity Policy Coalition (OPC), established by Cancer Council Victoria, Diabetes Australia (Victoria), the WHO Collaborating Centre for Obesity Prevention at Deakin University and VicHealth, made a submission to the Australian Government recommending the introduction of a tax on sugar-sweetened beverages. 

“With around 16 teaspoons of sugar in a standard 600mL bottle of soft drink, regular sugary drink consumption is a key contributor to overweight and obesity,” says OPC Executive Manager, Jane Martin. “Australian modelling shows that if a 20 per cent health levy on sugary drinks was introduced, 1600 more Australians could be alive in 25 years, having avoided premature death due to weight-related diseases including type 2 diabetes, heart disease and stroke.” 

The OPC further recommends using the revenue raised by a tax on sugar-sweetened drinks to fund programs designed to improve diets and reduce childhood obesity, in tandem with other strategies including restrictions on junk food marketing to children and mandatory application of the Health Star Rating System across all packaged foods. 

There is debate around the value of nutrient-specific interventions. On the positive side they can have impact, as the success of the sugar taxes shows. They’re also relatively easy to explain and communicate to consumers. On the negative side, they may undercut bigger goals around community-wide food literacy, increasing confusion around which advice to follow and undermining the individual’s capacity to make big changes in behaviour around food choices.

Professor Neal is a pragmatist who acknowledges that nutrient-specific advice is a relatively easy sell.

“It’s more straightforward to develop strategies that focus on a particular nutrient – and it’s much easier to explain to policymakers, community or industry than talking about a multitude of things,” he says.

He argues that the development and implementation of more holistic approaches is a far more complex task – but that it’s a challenge worth tackling.

“Almost everyone would agree that we want people to be eating things that are on average healthier in terms of all potential benefits and harms. The issue is in the practicalities of achieving that,” says Neal.

Another expert who questions the wisdom of nutrient-specific interventions is Dr Gyorgy Scrinis, a Senior Lecturer in Food Politics and Policy in the Faculty of Veterinary and Agricultural Sciences at the University of Melbourne. In his 2013 book, Nutritionism: The Science and Politics of Dietary Advice (Columbia University Press) he argues that a nutrient-specific focus has led at times to simplified or exaggerated advice about the health impacts of particular nutrients or foods.

“We need to develop other ways to talk about food,” he says. “For instance, if you are concerned about salt in your diet then you really should be concerned about highly-processed foods, because that’s where much of the salt comes from.

“Whether it’s focusing on whole foods or following some sort of traditional dietary pattern, there are many ways of understanding food quality and constructing healthy diets,” he adds.

 

Big picture policy

Debates about the value of big, broad approaches to improving community eating habits are taking place globally. New ‘people-and-planet-style’ dietary guidelines that pack together messages about whole foods, sustainable farming practices and the social context of food preparation and eating have captured the attention of food policymakers across the world.

One of several Latin American countries tackling issues of populations with over-nutrition and under-nutrition simultaneously, Brazil delivered a new set of dietary guidelines in 2014 that were like none before.

Echoing Pollan’s simple dietary messaging, Brazil’s new approach is easy to understand and bold in tone. Devised by Dr Carlos Monteiro, head of the University of Sao Paulo’s Centre for Epidemiological Studies in Health and Nutrition and a member of the World Health Organization Nutrition Guidance Expert Advisory Group, takes a holistic approach. “Diet refers to intake of nutrients, and also to the foods that contain and provide nutrients. Diet also refers to how foods are combined and prepared in the form of meals, how these meals are eaten, and also to cultural and social dimensions of food choices, food preparation and modes of eating, all of which affect health and wellbeing.”

Always prefer natural or minimally processed foods and freshly made dishes and meals to ultra-processed foods.

The Brazilian Dietary Guidelines have one golden rule. “Always prefer natural or minimally processed foods and freshly made dishes and meals to ultra-processed foods.”

Ultra-processed foods, summarised as packaged snacks, soft drinks and instant noodles, are “nutritionally unbalanced”, the Brazilian guidelines say. “As a result of their formulation and presentation, they tend to be consumed in excess, and displace natural or minimally processed foods. Their means of production, distribution, marketing and consumption damage culture, social life and the environment.”

With exhortations about mindful eating and food shopping, they go on to describe how eating in the company of others is a natural, simple yet profound way to create and develop relationships between people.

The guidelines’ final chapter on understanding and overcoming obstacles explains product placement in supermarkets, explores the impact of advertising and suggests ways of sourcing healthy foods, developing cooking skills, even growing a community garden.

This same approach to writing easily accessible guidelines that Brazil has adopted so effectively is also seen in the latest Australian Dietary Guidelines, at the eatforhealth.gov.au website. Summarised into five equally important clear guidelines for healthy living, these represent the new way of thinking about communicating to people advice on how to live a healthy life.

The Australian Dietary Guidelines

Guideline 1

To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs

 

Guideline 2

Enjoy a wide variety of nutritious foods from these five food groups every day

 

Guideline 3

Limit intake of foods containing saturated fat, added salt, added sugars and alcohol

 

Guideline 4

Encourage and support breastfeeding

 

Guideline 5

Care for your food and store it safely


 State action on salt

The Victorian Salt Reduction Partnership, led by VicHealth, is currently working with food manufacturers to reduce salt levels in a variety of packaged foods. The Partnership was established in response to recommendations made in The Case for State Action on Salt in Australia, a 2014 preliminary report by The George Institute for Global Health, a World Health Organization (WHO) Collaborating Centre on Population Salt Reduction.

 

Collaboration at all levels of government, and with health organisations, non-governmental organisations, non-profit organisations, research institutions and other relevant stakeholders is key to effective salt reduction programs, according to WHO.

One of the Partnership’s early outputs was the public release of the State of Salt: The case for salt reduction in Victoria in 2015 which outlined the role Victoria could play in meeting national and international targets.

A new consumer awareness campaign, Unpack the Salt, was launched in August 2017 and attracted widespread attention with the release of a report analysing cooking sauces. The research found that they’re packed with salt, with some brands nearly 100 times worse than others. The campaign will run until mid-2018 and aims to raise awareness and prompt debate with the release of a series of reports on salt levels in particular food categories.

Championing of food industry players who have reformulated products to significantly reduce salt levels in processed foods is planned through case studies that can be held up as examples to manufacturers who have been slower to act.

“The real message around reformulation is that it can be done,” says Jenny Reimers, VicHealth’s Principal Program Officer Healthy Eating. “Loads of companies are doing it – and the vast range of salt levels in similar products shows that you can actually reduce it, in some cases by huge amounts.”

Indeed, the Case for State Action on Salt in Australia presented ‘no brainer’ arguments for salt reduction strategies identified as one of the most cost-effective ways to reduce the burden of non-communicable diseases. It noted “one of the reasons that salt reduction is so straightforward is that fairly large quantities of salt can be taken out of foods without people noticing.”

The Salt Reduction Partnership is also supporting existing Victorian food policy frameworks, such as the Healthy Choices food and drink classification guide and setting-specific guidelines for hospitals and health services, workplaces, sports and recreation centres, and parks. “More and more organisations are signing up to this, showing the food industry there’s demand for healthier products, which can drive reformulation,” Reimers says.

“Our partnership is now looking for stronger targets for salt reduction to be set across more food categories, and for monitoring of compliance. There needs to be more push for industry to get on board – that’s a big part of the policy discussion. This is similar to what happened in the UK when they set salt targets in 2006 and with the threat of mandating across a range of food products amazing changes occurred.”

The final action point for the Partnership involves research, monitoring and evaluation. Separate research projects on the salt intake of adults and children in Victoria are being undertaken as part of the program.

Monitoring of salt intake in Australia is ad hoc, laments Reimers, citing the insights that come from data collected in the Australian Health Survey and the Victorian Health Monitor Food and Nutrition Report. “We really need to accurately quantify the level of nutrients being consumed nationally and on a regular basis,” she believes.

A partnership grant from the National Health and Medical Research Council supports the evaluation of the work of the Victorian Salt Reduction Strategic Partnership.

Victorian Salt Reduction Partnership: VicHealth, The George Institute for Global Health, Heart Foundation Victoria, Deakin University’s Institute for Physical Activity and Nutrition Research, National Stroke Foundation, Kidney Health Australia, the Victorian Department of Health and Human Services, Baker Heart and Diabetes Institute and the High Blood Pressure Research Council.