Alexandra Jones

Incorporating Added Sugar Improves the Performance of the Health Star Rating Front-of-Pack Labelling System in Australia.

Background: The Health Star Rating (HSR) is an interpretive front-of-pack labelling system that rates the overall nutritional profile of packaged foods. The algorithm underpinning the HSR includes total sugar content as one of the components. This has been criticised because intrinsic sugars naturally present in dairy, fruits, and vegetables are treated the same as sugars added during food processing. We assessed whether the HSR could better discriminate between core and discretionary foods by including added sugar in the underlying algorithm. Methods: Nutrition information was extracted for 34,135 packaged foods available in The George Institute’s Australian FoodSwitch database. Added sugar levels were imputed from food composition databases. Products were classified as ‘core’ or ‘discretionary’ based on the Australian Dietary Guidelines. The ability of each of the nutrients included in the HSR algorithm, as well as added sugar, to discriminate between core and discretionary foods was estimated using the area under the curve (AUC). Results: 15,965 core and 18,350 discretionary foods were included. Of these, 8230 (52%) core foods and 15,947 (87%) discretionary foods contained added sugar. Median (Q1, Q3) HSRs were 4.0 (3.0, 4.5) for core foods and 2.0 (1.0, 3.0) for discretionary foods. Median added sugar contents (g/100 g) were 3.3 (1.5, 5.5) for core foods and 14.6 (1.8, 37.2) for discretionary foods. Of all the nutrients used in the current HSR algorithm, total sugar had the greatest individual capacity to discriminate between core and discretionary foods; AUC 0.692 (0.686; 0.697). Added sugar alone achieved an AUC of 0.777 (0.772; 0.782). A model with all nutrients in the current HSR algorithm had an AUC of 0.817 (0.812; 0.821), which increased to 0.871 (0.867; 0.874) with inclusion of added sugar. Conclusion: The HSR nutrients discriminate well between core and discretionary packaged foods. However, discrimination was improved when added sugar was also included. These data argue for inclusion of added sugar in an updated HSR algorithm and declaration of added sugar as part of mandatory nutrient declarations.

Tobacco Control and Beyond: The Broader Implications of United States-Clove Cigarettes for Non-Communicable Diseases

This Article examines the implications of US - Clove Cigarettes and subsequent technical barriers to trade (TBT) disputes for tobacco control and control of non-communicable diseases (NCDs) associated with alcohol and poor diet. In US - Clove Cigarettes, the Appellate Body of the World Trade Organization (WTO) adopted an approach to non-discrimination under the TBT Agreement which requires WTO panels to assess the legitimacy of regulatory distinctions that affect the competitive opportunities of imported products negatively. This article argues that the effect of that test on domestic regulatory autonomy will depend greatly on the standards of proof to be used first in determining the legitimacy of regulatory distinctions and second in determining whether the effect of a regulation on competitive opportunities is based solely on such distinctions. In the context of NCDs, WTO panels will have to be sensitive to the limits of epidemiological evidence and to the fact that risk is based not only on the inherent features of products but also on consumer behavior.

Defining ‘Unhealthy’: A Systematic Analysis of Alignment between the Australian Dietary Guidelines and the Health Star Rating System

The Australian Dietary Guidelines (ADGs) and Health Star Rating (HSR) front-of-pack labelling system are two national interventions to promote healthier diets. Our aim was to assess the degree of alignment between the two policies. Methods: Nutrition information was extracted for 65,660 packaged foods available in The George Institute’s Australian FoodSwitch database. Products were classified ‘core’ or ‘discretionary’ based on the ADGs, and a HSR generated irrespective of whether currently displayed on pack. Apparent outliers were identified as those products classified ‘core’ that received HSR ≤ 2.0; and those classified ‘discretionary’ that received HSR ≥ 3.5. Nutrient cut-offs were applied to determine whether apparent outliers were ‘high in’ salt, total sugar or saturated fat, and outlier status thereby attributed to a failure of the ADGs or HSR algorithm. Results: 47,116 products (23,460 core; 23,656 discretionary) were included. Median (Q1, Q3) HSRs were 4.0 (3.0 to 4.5) for core and 2.0 (1.0 to 3.0) for discretionary products. Overall alignment was good: 86.6% of products received a HSR aligned with their ADG classification. Among 6324 products identified as apparent outliers, 5246 (83.0%) were ultimately determined to be ADG failures, largely caused by challenges in defining foods as ‘core’ or ‘discretionary’. In total, 1078 (17.0%) were determined to be true failures of the HSR algorithm. Conclusion: The scope of genuine misalignment between the ADGs and HSR algorithm is very small. We provide evidence-informed recommendations for strengthening both policies to more effectively guide Australians towards healthier choices.

An Evaluation of the Healthiness of the Indian Packaged Food and Beverage Supply

Availability of less-healthy packaged food and beverage products has been implicated as an important driver of obesity and diet-related disease. An increasing number of packaged foods and beverages are sold in India. Our objective was to evaluate the healthiness of packaged foods sold by India’s largest manufacturers. Healthiness was assessed using the Australian Health Star Rating (HSR) system and the World Health Organization’s European Regional Office (WHO Euro) Nutrient Profile Model. Sales-value-weighted mean healthiness and the proportions of “healthy” products (using a validated HSR cut-off of ≥3.5, and products meeting WHO Euro criteria as healthy enough to market to children) were calculated overall, by company and by food category. Nutrient information for 943 products sold by the 11 largest Indian manufacturers was obtained from nutrient labels, company websites or directly from the manufacturer. Healthiness was low overall (mean HSR 1.8 out of 5.0 stars) with a low proportion defined as “healthy” by both HSR (17%) and also by WHO Euro criteria (8%). There were marked differences in the healthiness of similar products within food categories. Substantial variation between companies (minimum sales-value-weighted mean HSR 0.5 for Company G, versus maximum HSR 3.0 for Company F) was a result of differences in the types of products sold and the nutritional composition of individual products. There are clear opportunities for India’s largest food companies to improve both the nutritional quality of individual products and to improve their product mix to include a greater proportion of healthy products.

Uptake of Australia’s Health Star Rating System

In June 2014, Australia and New Zealand adopted a voluntary front-of-pack nutrition labelling scheme in the form of the Health Star Rating (HSR) system. Our aim was to assess its uptake in Australia while a formal five-year review of the system is underway. Numbers and proportions of products eligible to carry a HSR were recorded each year between 2014 and 2017 as part of an annual survey of four large Australian retail outlets. 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, and for leading manufacturers. Results show that uptake is increasing: HSR appeared on 4348/15,767 (28%) of eligible products in 2017 and has now appeared on 7922 products since implementation. Of those products displaying a HSR logo, more than three-quarters (76.4%) displayed a HSR of ≥3.0. Products displaying a HSR logo had a higher mean HSR (3.4), compared to products not displaying a HSR logo (2.7). Uptake was highest on convenience foods (44%), cereals (36.7%), and fruit and vegetable products (35.9%). More than 100 manufacturers were using the system, but retailers Coles, Woolworths and Aldi were together responsible for 54% of uptake. For all except Coles, Woolworths and Campbell Arnott’s, the mean HSR of products displaying a logo on pack was higher than products made by that manufacturer not showing a HSR logo. We conclude that to ensure the consistent and widespread uptake required for consumers to make informed food purchases, HSR should be made mandatory at the conclusion of the five-year review.

The true price of sugar-sweetened disease: political inertia requires renewed, strategic action

xcess free sugars are a major contributor to dietrelated diseases, including obesity, type 2 diabetes E and tooth decay. Sugar-sweetened beverages (SSBs) provide a significant source of free sugars while offering no other nutritional benefit, making them a reasonable target for public health action. Governments worldwide are drawing on growing evidence to implement effective pricing policies for SSBs as one cornerstone of a comprehensive policy response.