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Nutrients 2018, 10(4), 501; https://doi.org/10.3390/nu10040501

Article
Defining ‘Unhealthy’: A Systematic Analysis of Alignment between the Australian Dietary Guidelines and the Health Star Rating System
1
The George Institute for Global Health, Sydney 2042, Australia
2
Charles Perkins Centre, University of Sydney, Sydney 2006, Australia
3
Division of Community Medicine, Primary Care, Department of Medicine and Health Sciences, Faculty of Health Sciences, Department of Local Care West, County Council of Östergötland, Linköping University, 581 83 Linköping, Sweden
4
Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
*
Author to whom correspondence should be addressed.
Received: 20 March 2018 / Accepted: 13 April 2018 / Published: 18 April 2018

Abstract

:
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.
Keywords:
nutrient profiling; front-of-pack labelling; dietary guidelines; nutrition policy; health star rating

1. Introduction

Unhealthy diets—high in salt, harmful fats, added sugar and energy—are a leading cause of death and disability in Australia [1]. Australia has some of the highest obesity rates in the world: nearly two-thirds of Australian adults and one in four children are now overweight or obese. Unprecedented availability and aggressive marketing of processed and pre-packaged foods and beverages are a key driver of obesity and diet-related conditions including high blood pressure, heart disease, stroke, type 2 diabetes, some forms of cancer, dementia and dental caries [2]. Obesity alone is estimated to cost Australia more than $8.6 billion annually [3].
The World Health Organization recommends a comprehensive suite of population health approaches to promote healthier diets. These include laws and regulations, tax and price interventions, community-based measures in facilities such as schools and hospitals, and public education through social marketing campaigns [4]. Despite the increasing impact of poor diet on Australia’s health, few of these preventive strategies have been taken up at a federal level.
Two policy areas where Australia has been benchmarked as performing well against international best-practice are in adoption of food-based dietary guidelines and front-of-pack nutrition labels [5]. The current Australian Dietary Guidelines (ADGs) were introduced in 2013 to promote health and wellbeing while reducing the risk of chronic disease [6]. In 2014, Australia adopted the Health Star Rating System (HSR), an interpretive nutrition labelling scheme that rates foods from 0.5 to 5.0 stars on the front-of-pack [7]. An example of the HSR graphic and the Australian Guide to Healthy Eating, which provides a practical visual representation the food groups recommended by the ADGs and their proportions, are included at Appendix A.
While inherently related in their intent to guide Australians towards healthier choices, the two measures differ in aspects of their purpose and design (Table 1). For example, the ADGs provide information on dietary patterns, amounts and food groups that support health through detailed guidance documents that are for use by health professionals, policy makers, educators, food manufacturers and researchers [6]. By contrast, HSR uses an algorithm to quantify selected aspects of individual foods, generating a summary score displayed in a simple symbol intended to both target consumers at the point-of-sale, and offer incentives for manufacturers to improve recipes to receive a higher rating [8,9]. The relative strengths of each measure suggest potential opportunities for the ADGs and HSR to operate synergistically for maximum public health impact. At the same time, tension between the two approaches is apparent in academic and media critique of HSR, particularly where high profile products have been highlighted for displaying labels allegedly inconsistent with ADG recommendations [10,11].
With a five year review of the HSR system currently underway, our objective was to assess one of the review’s key elements, namely the degree of alignment between the two policies and specifically in their mechanism for defining food as healthy or unhealthy. Policy coherence is important not only because of the need to provide consistent dietary messaging to Australians, but also because inappropriate HSR scores or ADG recommendations threaten the credibility and sustainability of both policies. By identifying areas and causes of misalignment, our aim was to make evidence-informed recommendations for refining both policies, thereby strengthening Australia’s efforts to promote healthier diets.

2. Methods

This was a cross-sectional examination of packaged foods and beverages (hereafter referred to as foods) available in Australia.

2.1. Data Source

We analysed items included in The George Institute for Global Health’s Australian FoodSwitch Database [12]. The database contains nutrition label information from packaged foods systematically collected by The George Institute through large-scale annual surveys, as well as provided directly by manufacturers and consumers on a rolling basis. In total, this data represents more than 90% of products available in the Australian market. For this study, we used information extracted directly from the back-of-pack nutrition information panel. Energy (kJ/100 g), protein (g/100 g), saturated fat (g/100 g), total sugar (g/100 g), and sodium (mg/100 g) are mandatory on the Australian nutrient declaration but details on fruit, vegetable, nut and legume (FVNL) (%), concentrated FVNL (%), and fibre (g/100 g) are optional. Where such details were absent, appropriate levels were estimated using information drawn from the back-of-pack ingredients list, generic food composition databases, or by analogy with similar products using methods described previously [12]. The estimation process provides a proxy value for each nutritional indicator at the finest category level for more than 1000 individual food subcategories. Proxy values are then substituted for each product in that category for which data are missing.

2.2. Product Classification

Classification of products was based on the system developed by the Global Food Monitoring Group and incorporated into FoodSwitch [13]. This hierarchical system is designed to monitor the nutrient composition of processed foods around the world. It classifies foods into major categories (e.g., bread and bakery products), categories (e.g., bread), and subcategories (e.g., pita bread). Our analysis included only packaged food items. We excluded infant foods and formula, vitamins and supplements, formulated supplementary sports foods, foods for special medical purposes and alcoholic beverages because these foods have been specifically deemed outside the scope of HSR [14]. This left 15 major categories for analysis. Within these, we also excluded subcategories of plain tea and coffee, herbs and spices, baking powders, yeasts and gelatines, as these foods do not contribute significantly to nutrient intake, are not required to display a nutrition information panel [15], and are also therefore not required to display a HSR.

2.3. Calculation of the Health Star Rating

The HSR was calculated in alignment with the methods described in the ‘Guide for industry to the Health Star Rating Calculator’ for all products sold, regardless of whether a HSR was reported on the pack [16]. In short, foods were categorised into one of six HSR categories (i.e., non-dairy beverages; dairy beverages; oils and spreads; cheese and processed cheese; all other dairy foods; all other non-dairy foods). Baseline points were calculated based on the energy, saturated fat, total sugar, and sodium content per 100 g. Modifying points for FVNL%, concentrated FVNL%, protein, and fibre were calculated, where applicable. A HSR ‘score’ was calculated by subtracting the modifying points from baseline points. This score is then converted to a HSR based upon a defined scoring matrix for each of the six categories [16]. The HSR ranges from 0.5 to 5.0 stars in ten half-star increments. A higher HSR reflects a healthier product.

2.4. Classification of Foods under the Australian Dietary Guidelines

We classified foods as ‘core’ or ‘discretionary’ according to ADG guidance. In short, core foods were defined as those from the ADGs Five Food Groups: grain (cereal) foods, mostly wholegrain and/or high cereal fibre varieties; vegetables and legumes/beans; fruit; milk, yoghurt, cheese and/or alternatives, mostly reduced fat; and lean meats and poultry, fish, eggs, tofu, nuts and seeds and legumes/beans. Together, these core foods form the basis of a healthy diet. Discretionary foods are those not necessary to provide nutrients the body needs, and are defined for ADG purposes as those ‘high in’ saturated fats, added sugars, and/or salt or alcohol [6]. As the ADG documents themselves provide only limited examples of discretionary choices and no objective measure of ‘high in’, we relied upon the Australian Bureau of Statistics (ABS) ‘Discretionary Food List’ [17] as the best-available reference for classifying each product for the purposes of this analysis. The main principle used by the ABS to classify foods as discretionary is that they were specified or inferred in the ADGs and supporting documents as discretionary [17]. ABS classifications determined at a detailed food category level were matched to FoodSwitch categories to classify each category as ‘core’ or ‘discretionary’.
In some categories, such as those involving mixed foods, the ABS applies additional nutrient criteria to define core and discretionary. The nutrient cut-offs specified are those used in the modelling that supported the original ADG development [18]. Where provided, e.g., pizza with saturated fat content ≤5 g/100 g is ‘core’ while pizza with saturated fat content >5 g/100 g is ‘discretionary’, these were also applied.

2.5. Statistical Analysis

Cross-tabulations of ADG status and HSR were prepared for the twenty cells comprising core, discretionary and the ten possible HSR values (0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5 or 5.0). In the absence of endorsed HSR cut-offs for healthy or unhealthy, we identified products as ‘apparent outliers’ when the product was categorised ‘core’ by the ADGs but received a HSR ≤ 2.0, suggesting an unhealthy nutritional profile, or the product was categorised as ‘discretionary’ by the ADG but received a HSR ≥ 3.5, suggesting a healthy nutritional profile. The number and proportion of products deemed apparent outliers was determined overall, for each of the 15 major food categories included and by category and sub-category where helpful.
To further understand the reasons for outlier status of products, and in particular the potential impact of the undefined ‘high in’ terminology used by the ADGs, we applied additional nutrient cut-off criteria. In the absence of any existing international standard or guidance, we drew from the United Kingdom (UK) multiple traffic-light nutrient profile model, which was validated during development in the UK context, and has been subsequently used to model dietary outcomes elsewhere [19,20,21]. Specifically, the cut points used to apply red traffic lights for salt, total sugar and saturated fat were used to provide a quantitative measure of the ADGs ‘high in’ terminology. These were applied to apparent outliers, and products were removed or retained on the basis of qualifying for none, one or multiple red traffic lights:
  • Apparent outliers that scored a low HSR but were assigned ‘core’ status by the ADGs were not considered ‘genuine outliers’ if they were sufficiently ‘high in’ salt, saturated fat and/or sugar to warrant at least one red traffic light.
  • Apparent outliers that scored a high HSR but were assigned ‘discretionary’ status by the ADGs were not considered ‘genuine outliers’ if nutrient values for salt, saturated fat and/or sugar were not sufficiently high to warrant at least one red traffic light.
Apparent outliers that were deemed not to be genuine outliers after application of these ‘high in’ cut points were deemed ‘ADG failures’. All others were deemed ‘HSR failures’. Reasons for failures and potential solutions were systematically recorded (Appendix B).

3. Results

In total, 65,660 packaged products available in Australian supermarkets between 1 January 2013 and 30 June 2017 were identified in the FoodSwitch database. Of these, 11,431 had insufficient product information to enable categorization and generate a HSR, and a further 7113 were in categories excluded from HSR.
This left 47,116 products for analysis. Of these, only 3524 (7.5%) were displaying HSR on pack at the date of data extraction (30 June 2017).

3.1. HSR Distribution by Core and Discretionary

There were 23,460 (49.8%) core products and 23,656 (50.2%) discretionary products. Distribution of HSR by core and discretionary is shown in Figure 1.
In total, the median (IQR) of calculated HSR scores was 3 (1.5 to 4). Core products had a median (IQR) calculated HSR score of 4.0 (3.0 to 4.5) and discretionary products had a median (IQR) calculated HSR score of 2.0 (1.0 to 3.0).
Of products displaying HSR on pack, the overall median (IQR) value was 4.0 (3.0 to 4.5); out of these, 2131 (60.5%) were core products and 1393 (39.5%) were discretionary.

3.2. Apparent Outliers

There were 6324 (13.4%) apparent outliers. In total, 2219 were apparent core outliers, representing 9.5% of all core products and 4.7% of the total sample. In total, 4105 apparent discretionary outliers were identified, representing 17.4% of all discretionary products and 8.7% of the total sample (Figure 1 and Table 2).
As seen in Figure 2, the distribution of products and number of apparent outliers varied greatly across the 15 major food categories and by core and discretionary classification. The major categories with the largest proportion of apparent outliers were sauces, dressings, spreads and dips (19.9%); dairy (18.4%); and snack foods (10.3%).

3.3. Application of Traffic Light Cut-Offs

Application of cut-points to identify foods ‘high in’ salt, total sugar and saturated fat greatly reduced the number of outliers (Table 2).
Among the apparent core outliers, 2116/2219 (95.4%) had at least one red traffic light, signifying high levels of salt (1159), saturated fat (1136), and/or sugar (538). These foods were deemed ADG failures on the basis that high levels of these negative nutrients form the basis of the ADG definition of discretionary foods. This left 103 (4.6%) core food outliers that received a low HSR despite not being ‘high in’ any negative nutrients. These results were genuinely misaligned with the ADGs and deemed HSR failures. Figure 3 and Table 3 detail these results by major food category. The three categories with HSR failures were fruit and flavoured yoghurts; and flavoured teas. The yoghurts had amber lights for saturated fat and sugar, and the flavoured teas had amber lights for sugar. Both categories likely had a mix of naturally occurring and added sugar.
In the discretionary outlier group, 3130/4105 (76.2%) of apparent outliers had no red traffic lights, signifying they were not ‘high in’ salt, sugar or saturated fat and were therefore deemed ADG failures. This left 975 (23.8%) apparent discretionary outliers receiving a high HSR despite being ‘high in’ salt (510), sugar (296) and/or saturated fat (235). These foods were deemed HSR failures. Figure 3 and Table 4 outline these findings by major food category. The largest number of HSR failures occurred in sauces, dressings, spreads and dips; savoury snacks; meat and meat products; and, convenience foods. Products in these categories predominantly had red traffic lights for salt and to a lesser degree, saturated fat despite receiving HSR ≥ 3.5.
Taking core and discretionary together, 5246 outliers (83%) were attributable to ADG failure. This left 1078 outliers (17%) attributable to a failure of the algorithm.
A detailed list of core and discretionary outliers is included at Appendix B.

4. Discussion

In contrast to intense media attention on occasional anomalies, this large quantitative analysis suggests that the scope of genuine misalignment between the ADGs and the HSR algorithm across the Australian food supply is very small.
The degree of policy coherence demonstrated by our results is encouraging, though perhaps not surprising given the well-recognised relationship between nutrients, foods and dietary patterns [22]. Our results are consistent with existing research demonstrating that the HSR algorithm is aligned well overall with the ADGs [23,24,25], and that the median HSR of core foods is significantly higher than that of discretionary foods [10,23,26].
While these results are promising, it is reasonable to seek better alignment between the HSR and the ADGs if this increases their public health impact. The results of this work suggest directions for improvement.
Specific recommendations for improving alignment are set out in Table 5.
While there is considerable current focus on review of the HSR algorithm, these results highlight a parallel urgent need for review of the ADG text and corresponding ABS Table (See Appendix B).
Our findings can be differentiated from a recent analysis of foods carrying HSR labels on pack during voluntary implementation [19]. That analysis of 1269 new products found that 57% were core items and 43% discretionary. The authors concluded that HSR labelling was undermining ADG recommendations by facilitating the marketing of discretionary foods because more than half of those defined as discretionary displayed a HSR ≥ 2.5. Our work suggests caution in this interpretation given the small sample size of the prior study, identified failings of the ADGs in regard to the classification of some foods, and the highly selective subset of products studied. The conclusions may also reflect the simplistic approach ultimately taken by the ADGs, in seeking to dichotomise foods as core or discretionary, when healthiness of products is almost certainly distributed along a continuum.
The present analysis benefits from the large number of foods included, their robust representation of the broader Australian food supply and the comprehensive and systematic approach taken to the evaluation and presentation of the data. Our decision to use the UK traffic light criteria as a quantitative measure of ‘high in’ was an objective approach to quantifying the textual guidance provided by the ADGs. The international food standards agency, The Codex Alimentarius Committee, recently agreed to commence work to develop ‘high in’ criteria for salt, sugar and saturated fat given increasing international interest in this area. This process is likely to take several years [27].
Some limitations also need to be mentioned. FVNL content and fibre are not currently mandatory on back-of-pack nutrition information panels in Australia and missing values were therefore estimated from ingredients lists, food composition databases, and other sources. This analysis does not capture related concerns raised by stakeholders to the Government’s five year review [28] regarding the high HSRs received by fruit juices, breakfast cereals with a sugar content ≤30 g/100 g, and breakfast beverages. These issues likely represent HSR failures but are not identified as ‘outliers’ in this analysis because the ADG text and/or ABS Table also identify these products (arguably incorrectly) as core.
Our ability to measure alignment was limited by the components of foods considered by the HSR algorithm. For example, HSR currently relies on total sugar but the ADGs recommend to limit added sugars specifically. Areas where we believe this distinction may have impacted outlier status include flavoured yoghurts and milks, breakfast cereals, muesli bars, chutneys and table sauces as noted in detail in Appendix B. Previous work has indicated that incorporating added sugar into the HSR algorithm would improve its ability to discriminate between core and discretionary [26,29]. This would be best facilitated by updating mandatory nutrient information panel (NIP) requirements to include transparent information on added sugars. Alternatively, added sugar values could be systematically estimated using available information from current NIPs in combination with the ingredients list, using published methods [30]. A similar approach is currently provided to companies claiming points for fruit, vegetable, nut and legume content that is also not required in the NIP.
Our analysis was also limited in scope to packaged products only. While half our sample were classified core (suggesting that not all packaged foods are unhealthy), some foods recommended by the ADGs (i.e., whole fresh fruit and vegetables) are generally sold without packaging. Current consideration of whether to extend HSR to these products (e.g., through shelf talkers) could further enhance alignment between the HSR and ADGs [31].

5. Conclusions

This work illustrates the complexity of defining foods as ‘healthy’ or ‘unhealthy’ across the huge range of packaged products available in the current Australian food supply.
Like other front-of-pack labelling systems that rely on an underlying profiling model, the HSR algorithm is intended as a tool to quantify selected aspects of individual foods rather than to be a complete source of dietary advice. Nevertheless, our results are consistent with WHO recognition that such tools are a helpful method to use in conjunction with interventions aimed at improving the overall nutritional quality of diets [32].
Rather than undue focus on perfect alignment or determination of the superiority of the HSR or ADGs, a more nuanced understanding of the relative contribution (and inherent limitations) of each suggests areas where the design and implementation of both policies could be strengthened to guide Australian consumers towards healthier choices.

Acknowledgments

A.J. is supported by an Australian Government Research Training Program (RTP) Scholarship. B.N. is supported by a National Health and Medical Research Council of Australia Principal Research Fellowship (APP1106947) and holds and NHMRC Program Grant (APP1052555) and Centre for Research excellence funding (APP1117300). K.R. is funded by a County Council of Östergötland international fellowship.

Author Contributions

A.J., K.R. and B.N. conceived and designed the research; A.J. and K.R. conducted the analysis (though K.R. conducted the statistical analysis specifically); A.J. wrote the first draft of the paper. K.R. and B.N. reviewed the manuscript and contributed to subsequent drafts.

Conflicts of Interest

Alexandra Jones is a member of the Technical Advisory Group (TAG) to the Australasian Health Star Rating Advisory Committee (HSRAC). Neither the TAG nor the HSRAC had any role in the study design, data collection, decision to publish, or preparation of the manuscript.

Appendix A. Australian Health Star Rating graphic and Australian Guide to Healthy Eating

(a) Health Star Rating system graphic
Nutrients 10 00501 i001
Examples of the HSR graphic to be applied to the front of packaged foods. The label can be applied in multiple acceptable configurations, with and without the addition of energy content and select nutrient information (in addition to the nutrient information panel mandated on the back of pack).
(b) The Australian Guide to Health Eating (AGHE)
The AGHE is a food selection guide and the primary education and promotional tool in the Australian Government’s Eat for Health Program [33]. It converts scientific knowledge of food composition and nutritional requirements for optimal health and wellbeing into a practical guide representing the proportion of ADGs Five Food Groups recommended for consumption each day.
For the purposes of this paper, Five Food Group foods, appearing within the circular ‘plate’ are referred to as ‘core’ foods. Foods in the bottom right corner stated to be for consumption ‘only sometimes and in small amounts’ are illustrative examples of ‘discretionary’ foods.
Nutrients 10 00501 i002
Source: Australian Government Eat for Health Website, available at https://www.eatforhealth.gov.au/guidelines/australian-guide-healthy-eating (accessed 8 April 2018).

Appendix B. Core and Discretionary Outliers by Major Food Group, Category, Traffic Light, ADG/HSR Failure and Policy Recommendation

(a) Core foods receiving HSR ≤ 2.0
Major Food Categories (Extracts of Relevant ADG Text *)nSaturated fat Traffic Light RedSodium Traffic Light RedTotal Sugar Traffic Light Redn ADG Failuren HSR FailurePolicy Recommendation (Where n ≥ 10)
Bread and Bakery
Guideline 2: Go for wholegrains. Wholemeal or wholegrain varieties are preferable because they provide more dietary fibre, vitamins and minerals than refined grain (cereal) foods...
Grain (cereal) foods which have high amounts of added saturated fats, added sugars, and/or salt such as most cakes, muffins, pies, pastries and biscuits are not included in this group but are classified ‘discretionary’ choices.
 Biscuits
  Savoury biscuits7649658742Review ABS table, including kJ cut-off for biscuits
  Plain dry biscuits494220481Review ABS table, including kJ cut-off for biscuits
 Bread
  Flat bread296240291None. Less healthy options of core foods
  Other bread2011018200None. Less healthy options of core foods
 Cakes, muffins and pastries
  Pancake mix171126143Review ABS table
  Crepe mix441440
Cereal and grain products
Guideline 2: Go for wholegrains. Wholemeal or wholegrain varieties are preferable because they provide more dietary fibre, vitamins and minerals than refined grain (cereal) foods...
Grain (cereal) foods which have high amounts of added saturated fats, added sugars, and/or salt such as most cakes, muffins, pies, pastries and biscuits are not included in this group but are classified ‘discretionary’ choices.
 Noodles
  Flavoured noodles8879831880Review ABS table
  Plain noodles623051
 Pastas
  Packet pastas280280280Review ABS table
  Fresh filled pasta101040100
  Plain dry pasta303030
 Other grains and cereals (e.g., breadcrumbs)111110110Review ABS table
 Breakfast cereals
  Muesli660160
  Granola440240
  Flakes303030
  Sweet cereals310330
  Others200111
 Rice
  Packet flavoured rice404010
  Dry rice101010
 Cous cous505050
Confectionery------
Convenience foods
Guideline 2: Eat a wide variety of nutritious foods from the five food groups…
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
 Pre-prepared salads and snacks
  Antipasto144121131Review ABS table
  Others (salad, sushi, sandwich)838180
 Pizza200184180Review ABS table. Consider salt cut-off
 Other frozen foods not specified993090
 Soups303030
Dairy
Guideline 2: Include milk, yoghurt and cheese and/or alternatives—mostly reduced fat
Full fat cheeses should be limited to 2–3 serves per week, and varieties which are lower in salt are preferable
 Cheese
  Hard and semi-hard cheeses28328327002830Review ABS table, core status given salt and sat fat
  Soft cheeses1771777301770Review ABS table, core status given salt and sat fat
  Processed cheeses3030300300Review ABS table, core status given salt and sat fat
  Sheep/goat cheese1313120130Review ABS table, core status given salt and sat fat
  Soy cheese999090Review ABS table, core status given salt and sat fat
 Yoghurt
  Yoghurt with fruit20482014516341Review ABS table, core status given sat fat and sugar
HSR failures suggest review sugar, added sugars
  Flavoured yoghurt105640759510Review ABS table, core status given sat fat and sugar
HSR failures suggest review sugar, added sugars
  Natural yoghurts575306552Review ABS table, core status given sat fat and sugar
  Non-dairy yoghurts (coconut)232300230Review ABS table (Coconut products)
  Yoghurt mixes246022222HSR impacted by ‘as prepared’
  Yoghurts with muesli or non-fruit additions1911018190Review ABS table, core status given sat fat and sugar
Review sugar, added sugars in HSR algorithm
  Drinking yoghurt100001
 Milks
  Coconut milks and creams797900790Review ABS table (Coconut products)
  Dairy milks1915015190Review ABS table, core status given sat fat and sugar
Review sugar, added sugars in HSR algorithm
  Other milks222020
 Cream products
  Mascarpone990090
 Desserts (crème caramel)220220
Edible oils and oil emulsions
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
Replace high fat foods which contain predominately saturated fats such as butter, cream, cooking margarine, coconut and palm oil with foods which contain predominately polyunsaturated and monounsaturated fats such as oils, spreads, nut butters/pastes and avocado.
 Coconut oils434300430Review ABS table. ADG text suggest avoid.
 Cooking oils (e.g., rice bran)161600160Review ABS table
 Edible oils (e.g., margarine)111100110Review ABS table
 Cooking spray oils (e.g., coconut)330030
Eggs------
Guideline 2: Choose lean meat and poultry, fish, eggs and/or plant-based alternatives
Fish and fish products
Guideline 2: Choose lean meat and poultry, fish, eggs and/or plant-based alternatives
Fresh, frozen and canned varieties of meats, poultry or fish are all suitable, but choose varieties that are low in salt and saturated fat. Processed meats such as salami, mettwurst, bacon and ham are not part of this food group. They are classified as discretionary choices because they are high in saturated fat and/or salt.
 Chilled fish
  Smoked salmon821820820Review ABS table
  Other chilled raw fish734161
 Canned fish
  Anchovies242240240Review ABS table
  Canned herring908080
  Canned salmon503032
  Other canned fish854080
 Other fish products not specified289240271Review ABS table
Fruit and vegetables
Guideline 2: Tuck into vegetables and fruit. Fresh, frozen, canned or dried varieties of vegetables and fruit are all suitable foods. Check the ingredients list and choose varieties of canned vegetables without added salt and canned fruit in natural juice, not syrup
Vegetables and fruit to limit: …dried fruit can also stick to the teeth and increase the risk of tooth decay. For this reason…dried fruit should be consumed only occasionally and in small amounts.
The intake of some salted, dried, fermented or pickled vegetables has been associated with increased risk of some cancers, so intake of these foods should be limited. Also limit intake of fried vegetables such as potato and vegetable chips and crisps, which add extra kilojoules and salt. Chips and crisps are included in ‘discretionary choices’
 Fruit
  Dried fruit5450343540Review ABS table and ADG text on dried fruit
  Fruit-based products (e.g., date balls)205118200Review ABS table and ADG text on dried fruit
  Coconut chunks101044100Review ABS table (coconut products)
  Fruit in syrup330330
 Vegetables
  Sundried tomatoes616460
  Other veg. products (namkeem, fried shallot)321030
 Nuts and seeds
  Nuts, salted and sweet-coated663360
 Herbs and spices
  Herb pastes3203214320Review ABS table. Potential new category
  Spice mixes439385430Review ABS table. HSR impacted by as prepared.
  Curry powders404040
Meat and Meat Products
Guideline 2: Choose lean meat and poultry, fish, eggs and/or plant-based alternatives
Fresh, frozen and canned varieties of meats, poultry or fish are all suitable, but choose varieties that are low in salt and saturated fat. Processed meats such as salami, mettwurst, bacon and ham are not part of this food group. They are classified as discretionary choices because they are high in saturated fat and/or salt.
 Pate and meat spreads5149170510Review ABS table
 Raw flavoured meats4138202410Review ABS table. Further meat categories needed
 Sausages and hot dogs370371370Review ABS table. Consider salt cut-off
 Meat not otherwise specified1510120150Review ABS table. Further meat categories needed
 Raw flavoured meats836080
 Uncoated frozen/chilled processed meat625060
 Kebabs322030
 Burgers303030
Non-alcoholic beverages
Guideline 2: Tea and coffee provide water, although they are not suitable for young children and large quantities can have unwanted stimulant effects in some people.
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
 Teas (not plain)422091032Review ABS table.
HSR failures suggest review added sugars
 Fruit juices400331
Sauces, dressings, dips and spreads
Guideline 3: Limit intake of foods high in saturated fats, added salt, added sugars and alcohol.
 Vinegars11048110Review ABS table
Special foods
Not specifically covered
  Meal replacements75214670750Review ABS table and eligibility for HSR.
HSR impacted by ‘as prepared’
Sugars, honey and syrups
Guideline 3: Limit intake of foods high in saturated fats, added salt, added sugars and alcohol.
Foods and drinks that are artificially sweetened can provide a useful alternative to those high in added sugars.
 Sweeteners200020200Review ABS table and ADG text on artificial sweeteners
TOTAL2219113611595382116103
* For the purposes of this Appendix we have extracted direct statements from the Australian Dietary Guidelines Summary Document: https://www.nhmrc.gov.au/_files_nhmrc/file/your_health/healthy/nutrition/n55a_australian_dietary_guidelines_summary_131014_1.pdf.
(b) Discretionary Outliers with HSR ≥ 3.5
Major Food Categories (Extracts of Relevant ADG text *)nSaturated Fat Traffic Light RedSodium Traffic Light RedTotal Sugar Traffic Light Redn
ADG Failure
n
HSR Failure
Policy Recommendation (Where n ≥ 10)
Breads and bakery
Guideline 2: Go for wholegrains. Wholemeal or wholegrain varieties are preferable because they provide more dietary fibre, vitamins and minerals than refined grain (cereal) foods...
Grain (cereal) foods which have high amounts of added saturated fats, added sugars, and/or salt such as most cakes, muffins, pies, pastries and biscuits are not included in this group but are classified ‘discretionary’ choices.
 Bread
  Savoury breads36120333Mostly healthier options of discretionary foods
  Sweet breads17014125Mostly healthier options of discretionary foods
  Others (garlic bread, ice cream cone, taco shell)25000250None. Healthier options of discretionary foods
 Biscuits
  Savoury biscuits (crackers and crispbreads)20021173Mostly healthier options of discretionary foods
Review ABS table and kJ cut-off savoury biscuits
  Sweet unfilled biscuits (plain, fruit and nut)17005125Mostly healthier versions of discretionary foods
  Plain dry biscuits12000120None. Healthier options of discretionary foods
 Cakes, Muffins and Pastries
  Pastries (filo sheets, quiches)24610177Mostly healthier versions of discretionary foods
  Cake mixes801071
  Cakes800171
Cereal and Grain Products
Guideline 2: Go for wholegrains. Wholemeal or wholegrain varieties are preferable because they provide more dietary fibre, vitamins and minerals than refined grain (cereal) foods...
Grain (cereal) foods which have high amounts of added saturated fats, added sugars, and/or salt such as most cakes, muffins, pies, pastries and biscuits are not included in this group but are classified ‘discretionary’ choices.
 Cereal and nut-based bars
  Cereal bars158112213424Mostly healthier versions of discretionary foods
HSR failures suggest review sugar, added sugars
  Nut-based bars4630123214Mostly healthier versions of discretionary foods
HSR failures suggest review sugar, added sugars
  Puff-based bars900181
 Ready-to-eat breakfast cereals
  Sweet, cocoa-based and puff cereals3800251325HSR failures suggest review sugar, added sugars
Review ABS table. Sugar cut-off for breakfast cereals (30/100 g, 35/100 g with fruit) already high.
  Breakfast cookie/rusk900181
 Other cereal products
  Stuffing mixes200020Healthier versions of discretionary foods
Confectionery
Guideline 3: Limit intake of foods high in saturated fats, added salt, added sugars and alcohol.
Limit intake of foods and drinks containing added sugars such as confectionary (sic)
 Chewing gums75000750Review application of HSR
 Jelly63007577Mostly healthier versions of discretionary foods
HSR failures suggest review sugar, added sugars
 Chocolate and sweets36401315Mostly healthier versions of discretionary foods
HSR failures suggest review saturated fat
Convenience foods
Guideline 2: Eat a wide variety of nutritious foods from the five food groups…
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
 Ready meals
  Frozen ready meals1802224713644Many healthier versions of discretionary foods
Review ABS table: complexity of classification highlights diversity of products.
HSR failures suggest review salt and saturated fat
  Ambient ready meals127102249829As above
  Chilled ready meals97502164057As above
  Others (meal kits)823144
 Soup
  Dry Soup mixes (as prepared with water)96002942ABS table review
HSR impacted by ‘as prepared’
Dairy
Guideline 2: Include milk, yoghurt and cheese and/or alternatives—mostly reduced fat
Some other milk products, such as ice-cream, can be relatively high in saturated fat and added sugars, so are classified under discretionary choices, together with cream and butter.
 Ice creams and edible ices
  Edible ices28002262None. Healthier options of discretionary foods
  Ice creams16001151None. Healthier options of discretionary foods
  Frozen yoghurt400222
  Soy-based ice cream200020
 Desserts
  Rice puddings310027427HSR failures suggest review sugar, added sugars
  Other prepared desserts, mousses18000180None. Healthier options of discretionary foods
  Dessert mixes910172
 Milks
  Probiotic drinks900545
Edible oils and oil emulsions
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
Replace high fat foods which contain predominately saturated fats such as butter, cream, cooking margarine, coconut and palm oil with foods which contain predominately polyunsaturated and monounsaturated fats such as oils, spreads, nut butters/pastes and avocado.
 Edible oils210102
Eggs------
Fish and fish products
Guideline 2: Choose lean meat and poultry, fish, eggs and/or plant-based alternatives
Fresh, frozen and canned varieties of meats, poultry or fish are all suitable, but choose varieties that are low in salt and saturated fat. Processed meats such as salami, mettwurst, bacon and ham are not part of this food group. They are classified as discretionary choices because they are high in saturated fat and/or salt.
 Processed fish
  Frozen fish219013013113Review ABS table Most are healthier versions of discretionary foodsHSR failures suggest review salt
Fruit and vegetables
Guideline 2: Tuck into vegetables and fruit. Fresh, frozen, canned or dried varieties of vegetables and fruit are all suitable foods. Check the ingredients list and choose varieties of canned vegetables without added salt and canned fruit in natural juice, not syrup.
Vegetables and fruit to limit: …dried fruit can also stick to the teeth and increase the risk of tooth decay. For this reason…dried fruit should be consumed only occasionally and in small amounts.
The intake of some salted, dried, fermented or pickled vegetables has been associated with increased risk of some cancers, so intake of these foods should be limited. Also limit intake of fried vegetables such as potato and vegetable chips and crisps, which add extra kilojoules and salt. Chips and crisps are included in ‘discretionary choices’.
 Vegetables
  Pickled vegetables155135311738Many healthier options of discretionary foods
HSR failures suggest review salt
  Frozen potato products1251001241Review ABS table ‘Potato Products’
Healthier options of discretionary foods
 Fruit
  Fruit bars and bites524046547HSR failures suggest review sugar, added sugars
  Jams and marmalades400040
 Seasonings11000110Review ABS table
Meat and meat products
Guideline 2: Choose lean meat and poultry, fish, eggs and/or plant-based alternatives.
Fresh, frozen and canned varieties of meats, poultry or fish are all suitable, but choose varieties that are low in salt and saturated fat. Processed meats such as salami, mettwurst, bacon and ham are not part of this food group. They are classified as discretionary choices because they are high in saturated fat and/or salt.
 Frozen and chilled meats
  Coated/breaded/frozen meats152817012824Mostly healthier options of discretionary foods
HSR failures suggest review salt, saturated fat
  Meat with pastry5736602037Some healthier options of discretionary foods
HSR failures suggest review saturated fat, salt
 Sliced meats10408402084Some healthier options of discretionary foods
HSR failures suggest review salt
 Canned meats4611103412Many healthier options of discretionary foods
HSR failures suggest review salt
 Salami and cured meats821053
 Burgers770007
 Dried meats600060
 Bacon403013
Non-alcoholic beverages
Water is essential for life. Choose water instead of drinks with added sugars or alcohol…Consumption of drinks with added sugars, such as soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks can increase risk of excessive weight gain in both children and adults. Water has an advantage over these drinks, and also over fruit juice and artificially sweetened soft drinks…
 Hot chocolate, milk flavourings220015157HSR impacted by as prepared
HSR failures suggest review sugar, added sugars
 Beverage mixes600151
 Electrolyte drinks200020
Sauces, dressings, spreads and dips
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
Tips to eat less saturated fat: … cut down on dishes with cream, buttery or creamy sauces or fatty gravy, instead choose tomato-based dishes.
Limit foods high in added sugars including… sweetened sauces and dressings…
 Sauces
  Pasta sauces
   Tomato-based pasta sauces389215137118Mostly healthier options of discretionary foods
Review ABS table, tomato sauces home vs commercial
HSR failures suggest review salt
   Cream-based pasta sauces37440298Many healthier options of discretionary foods
HSR failures suggest review saturated fat, salt
   Meat-based pasta sauces15010141None. Mostly healthier options of discretionary foods
  Meal-based sauces
   Ambient meal-based sauces84415759Mostly healthier options of discretionary foods
HSR impacted by as prepared
   Powdered meal-based sauces444713311Many healthier options of discretionary foods
HSR impacted by as prepared
   Liquid recipe bases4111402615Many healthier options of discretionary foods
HSR impacted by as prepared
HSR failures suggest review salt
   Curry pastes1101192Mostly healthier options of discretionary foods
  Gravies and stocks16000160Mostly healthier options of discretionary foods
HSR impacted by as prepared
  Table sauces54011152826Some healthier options of discretionary foods
HSR failures suggest review salt, sugar, added sugars
  Meat accompaniments24013204Mostly healthier options of discretionary foods
HSR failures suggest review sugar, added sugars
 Spreads and dips
  Dips
   Vegetable- based chilled dips (hummus, tzatziki, guacamole)292922126230Mostly healthier options of discretionary foods
HSR failures suggest review salt, saturated fat
   Salsa6801605216Mostly healthier options of discretionary foods
HSR failures suggest review salt
  Savoury spreads
   Relishes, pickles and chutneys124019574876Some healthier options of discretionary foods
HSR failures suggest review salt, sugar, added sugars
   Other savoury spreads702052
  Other spreads15308411HSR failures suggest review sugar, saturated fat
  Salad dressings and vinegars10000100None. Healthier options of discretionary foods
Snack foods
Guideline 2: Vegetables and fruit to limit…Limit intake of fried vegetables such as potato and vegetable chips and crisps, which add extra kilojoules and salt. Chips and crisps are included in ‘discretionary choices’
Guideline 3: Limit intake of foods containing saturated fats, added salt, added sugars and alcohol.
 Potato chips246246019849Many healthier options of discretionary foods
HSR failures suggest review salt, FVNL points
 Other snackfoods127213058047Many healthier options of discretionary foods
HSR failures suggest review salt, sat fat, FVNL points
 Corn chips91171705734Many healthier options of discretionary foods
HSR failures suggest review salt, sat fat, FVNL points
 Snack packs23000230Review ABS table definitions
 Vege-based snacks6253252438Some healthier options of discretionary foods
HSR failures suggest review salt, saturated fat, sugar, FVNL points
 Popcorn55221505Mostly healthier options of discretionary foods
Special foods
Not specifically covered in ADG text.
 Special foods200020
Sugars, honey and related products
Guideline 3: Limit intake of foods high in saturated fats, added salt, added sugars and alcohol.
Limit foods high in added sugars including…syrups…
 Syrups1400559HSR failures suggest review sugar
 Sugars100001
TOTAL41052355102963130975
* For the purposes of this Appendix we have extracted direct statements from the Australian Dietary Guidelines Summary Document: https://www.nhmrc.gov.au/_files_nhmrc/file/your_health/healthy/nutrition/n55a_australian_dietary_guidelines_summary_131014_1.pdf.

References

  1. Lim, S.S.; Vos, T.; Flaxman, A.D.; Danaei, G.; Shibuya, K.; Adair-Rohani, H.; Amann, M.; Anderson, H.R.; Andrews, K.G.; Aryee, M.; et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the global burden of disease study 2010. Lancet (Lond. Engl.) 2012, 380, 2224–2260. [Google Scholar] [CrossRef]
  2. Stuckler, D.; McKee, M.; Ebrahim, S.; Basu, S. Manufacturing epidemics: The role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS Med. 2012, 9, e1001235. [Google Scholar] [CrossRef] [PubMed]
  3. PricewaterhouseCoopers. Weighing the Cost of Obesity: A Case for Action; PricewaterhouseCoopers: Sydney, Australia, 2015. [Google Scholar]
  4. World Health Organization. ‘Best Buys’ and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases, Updated (2017) Appendix 3 of the Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020; World Health Organization: Geneva, Switzerland, 2017. [Google Scholar]
  5. Sacks, G.; for the Food-EPI Australia Team. Policies for Tackling Obesity and Creating Healthier Food Environments: Scorecard and Priority Recommendations for Australian Governments; Deakin University: Melbourne, Australia, 2017. [Google Scholar]
  6. National Health and Medical Research Council. Australian Dietary Guidelines; National Health and Medical Research Council (NHMRC): Canberra, Australia, 2013.
  7. Senator the Hon Fiona Nash Assistant Minister for Health. Media Release: Health Star Rating System on Track; Senator the Hon Fiona Nash Assistant Minister for Health: Canberra, Australia, 2014.
  8. Department of Health. The health Star Rating System (Website). Available online: http://healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/content/home (accessed on 27 July 2017).
  9. Australia and New Zealand Food Regulation Ministerial Council. Front of Pack Labelling Policy Statement. Available online: http://foodregulation.gov.au/internet/fr/publishing.nsf/Content/7F1E2F73C65A6463CA25801B0010D7FB/$File/2009-10-Forum-Policy%20Statement-Front%20of%20Pack%20Labelling.pdf (accessed on 18 April 2018).
  10. Lawrence, M.; Dickie, S.; Woods, J. Do nutrient-based front-of-pack labelling schemes support or undermine food-based dietary guideline recommendations? Lessons from the Australian health star rating system. Nutrients 2018, 10, 32. [Google Scholar] [CrossRef] [PubMed]
  11. Lawrence, M.; Pollard, C. A year on, Australia’s health star food-rating system is showing cracks [online]. J. Home Econ. Inst. Aust. 2015, 22, 34–35. [Google Scholar]
  12. Dunford, E.; Trevena, H.; Goodsell, C.; Ng, K.H.; Webster, J.; Millis, A.; Goldstein, S.; Hugueniot, O.; Neal, B. Foodswitch: A mobile phone app to enable consumers to make healthier food choices and crowdsourcing of national food composition data. JMIR mHealth uHealth 2014, 2, e37. [Google Scholar] [CrossRef] [PubMed]
  13. Dunford, E.; Webster, J.; Metzler, A.B.; Czernichow, S.; Mhurchu, C.N.; Wolmarans, P.; Snowdon, W.; L’Abbe, M.; Li, N.; Maulik, P.K. International collaborative project to compare and monitor the nutritional composition of processed foods. Eur. J. Prev. Cardiol. 2012, 19, 1326–1332. [Google Scholar] [CrossRef] [PubMed]
  14. Health Star Rating Advisory Committee (HSRAC). Health Star Rating System Style Guide V4, 4th ed.; Health Star Rating Advisory Committee (HSRAC): Canberra, Australia, 2016.
  15. Australia New Zealand Food Standards Code—Standard 1.2.8—Nutrition Information Requirements. Available online: https://www.legislation.gov.au/Details/F2011C00537 (accessed on 18 April 2018).
  16. Health Star Rating Advisory Committee (HSRAC). Guide for Industry to the Health Star Rating Calculator (HSRC); version 5; Department of Health, Ed.; Health Star Rating Advisory Committee (HSRAC): Canberra, Australia, 2016.
  17. Australian Bureau of Statistics. Australian Health Survey: Users’ Guide, 2011–13—Discretionary Food List; Australian Bureau of Statistics: Canberra, Australia, 2014.
  18. National Health and Medical Research Council. A Modelling System to Inform the Revision of the Australian Guide to Healthy Eating; National Health and Medical Research Council (NHMRC): Canberra, Australia, 2011.
  19. United Kingdom Department of Health. Guide to Creating a Front of Pack (Fop) Nutrition Label for Pre-Packed Products Sold Through Retail Outlets; Department of Health, Ed.; United Kingdom Department of Health: London, UK, 2016.
  20. Emrich, T.E.; Qi, Y.; Lou, W.Y.; L’Abbe, M.R. Traffic-light labels could reduce population intakes of calories, total fat, saturated fat, and sodium. PLoS ONE 2017, 12, e0171188. [Google Scholar] [CrossRef] [PubMed]
  21. Julia, C.; Ducrot, P.; Lassale, C.; Fézeu, L.; Méjean, C.; Péneau, S.; Touvier, M.; Hercberg, S.; Kesse-Guyot, E. Prospective associations between a dietary index based on the british food standard agency nutrient profiling system and 13-year weight gain in the su. Vi. Max cohort. Prev. Med. 2015, 81, 189–194. [Google Scholar] [CrossRef] [PubMed]
  22. Tapsell, L.C.; Neale, E.P.; Satija, A.; Hu, F.B. Foods, nutrients, and dietary patterns: Interconnections and implications for dietary guidelines. Adv. Nutr. 2016, 7, 445–454. [Google Scholar] [CrossRef] [PubMed]
  23. Dunford, E.; Cobcroft, M.; Thomas, M.; Wu, J. Technical Report: Alignment of the NSW Healthy Food Provision Policy with the Health Star Rating System; NSW Ministry of Health: Sydney, Australia, 2015.
  24. Wellard, L.; Hughes, C.; Watson, W.L. Investigating nutrient profiling and health star ratings on core dairy products in australia. Public Health Nutr. 2016, 19, 2860–2865. [Google Scholar] [CrossRef] [PubMed]
  25. Carrad, A.M.; Louie, J.C.Y.; Yeatman, H.R.; Dunford, E.K.; Neal, B.C.; Flood, V.M. A nutrient profiling assessment of packaged foods using two star-based front-of-pack labels. Public Health Nutr. 2016, 19, 2165–2174. [Google Scholar] [CrossRef] [PubMed]
  26. Peters, S.A.; Dunford, E.; Jones, A.; Ni Mhurchu, C.; Crino, M.; Taylor, F.; Woodward, M.; Neal, B. Incorporating added sugar improves the performance of the health star rating front-of-pack labelling system in australia. Nutrients 2017, 9, 701. [Google Scholar] [CrossRef] [PubMed]
  27. Codex Alimentarius Commission Committee on Food Labelling. Report of the Forty Fourth Session of the Codex Commitee on Food Labelling; Codex Alimentarius Commission Committee on Food Labelling: Ascunsion, Paraguay, 2017. [Google Scholar]
  28. MP Consulting. Report on Submissions to the Five Year Review of the Health Star Rating System: Prepared for the commonwealth Department of Health; MP consulting: Melbourne, Australia, 2017. [Google Scholar]
  29. Menday, H.; Neal, B.; Wu, J.H.Y.; Crino, M.; Baines, S.; Petersen, K.S. Use of added sugars instead of total sugars may improve the capacity of the health star rating system to discriminate between core and discretionary foods. J. Acad. Nutr. Diet. 2017, 117, 1921–1930.e1911. [Google Scholar] [CrossRef] [PubMed]
  30. Louie, J.C.Y.; Moshtaghian, H.; Boylan, S.; Flood, V.M.; Rangan, A.; Barclay, A.; Brand-Miller, J.; Gill, T. A systematic methodology to estimate added sugar content of foods. Eur. J. Clin. Nutr. 2015, 69, 154. [Google Scholar] [CrossRef] [PubMed]
  31. MP Consulting. Five Year Review of the Health Star Rating System—Navigation Paper; MP Consulting: Melbourne, Australia, 2018. [Google Scholar]
  32. World Health Organization. Nutrient Profiling. Available online: http://www.who.int/nutrition/topics/profiling/en/ (accessed on 1 February 2017).
  33. National Health and Medical Research Council. Eat for Health Educators Guide; National Health and Medical Research Council (NHMRC): Camberra, Australia, 2013.
Figure 1. Distribution of HSR by core and discretionary with apparent outliers.
Figure 1. Distribution of HSR by core and discretionary with apparent outliers.
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Figure 2. Apparent core and discretionary outliers—numbers of products and numbers of outliers by major food category.
Figure 2. Apparent core and discretionary outliers—numbers of products and numbers of outliers by major food category.
Nutrients 10 00501 g002
Figure 3. Apparent and genuine outliers by major food category (areas of circles are proportional to numbers of products).
Figure 3. Apparent and genuine outliers by major food category (areas of circles are proportional to numbers of products).
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Table 1. Key features of Australian Dietary Guidelines and the Health Star Rating System.
Table 1. Key features of Australian Dietary Guidelines and the Health Star Rating System.
ObjectiveMechanismTarget AudienceClassification of FoodsDeveloped byGoverned by
Australian Dietary GuidelinesProvide information on food groups, amounts and dietary patterns that support health.Guideline Documents, Summary and Educator Guide.
Australian Guide to Healthy Eating graphic
Health professionals, policy makers, educators, food manufacturers, food retailers and researchers.Classification of foods into Five Food Groups that form the basis of a healthy diet, and ‘discretionary’ foods defined by the presence of saturated fat, added sugars, salt and/or alcohol, whose intake is to be limited.National Health and Medical Research Council (NHMRC) via standardised guideline process.
Working Committee incl. public health and industry representation.
NHMRC
NHMRC considers whether to update after 5 years.
Maximum interval prior to update is 10 years.
Health Star RatingSimplify nutrition information available on back-of-pack to differentiate between individual foods more likely to be part of a healthy diet from those that are less healthy.Front-of-pack label to be applied voluntarily by food retailers and manufacturers using relevant policy documents.Consumers at point of purchase.
Food retailers and manufacturers.
A nutrient profile model is used to score individual products from 0.5 to 5.0 stars. The algorithm considers energy, negative nutrients the ADGs recommend eating less of (saturated fat, sugars and sodium), and foods the ADGs recommend eating more of (fruits, vegetables, nuts and legumes) as well as in some instances, allowing points for protein and dietary fibre content.Australian Fed., State and territory governments in partnership with food industry, consumer and public health groups.Health Star Rating Advisory Committee.
Representation from Australian Federal, State and Territory governments as well as food industry, consumer and public health groups.
2 year monitoring report and 5 year review process set down at adoption.
Table 2. Cross tabulation of apparent outliers, and attribution of reason for outlier status (i.e., ADG failure or HSR failure) after application of traffic light cut-offs.
Table 2. Cross tabulation of apparent outliers, and attribution of reason for outlier status (i.e., ADG failure or HSR failure) after application of traffic light cut-offs.
Apparent OutliersADG FailureHSR Failure
HSR ≤ 2.022192116103
HSR ≥ 3.541053130795
Table 3. Core products with HSR ≤ 2.0.
Table 3. Core products with HSR ≤ 2.0.
Major Food CategoryNumber of Apparent OutliersNumber of Products with Any Red TLLOutliers RemainingIllustrative Examples of Outliers RemainingCharacteristics of Remaining Outliers
1 Bread and bakery products1931876Pancake mixes, tortillas
  • All have amber traffic lights for saturated fat and salt, and some also for sugar
2 Cereal and grain products1741722Rice puff cereal, noodles
  • Breakfast cereal has amber lights for salt and sugar
  • Noodles have amber lights for saturated fat and salt
3 Confectionery0-- -
4 Convenience foods57561Antipasto product
  • Has amber traffic lights for salt, saturated fat and sugar
5 Dairy105699758Fruit and flavoured yoghurts, natural yoghurt
  • All are in yoghurt category. More than 90% are yoghurts with fruit or flavourings that have amber traffic lights for saturated fat and sugar
  • Two products are natural yoghurts with amber traffic lights for saturated fat and salt
6 Edible oils and oil emulsions73730 -
7 Eggs0-- -
8 Fish and fish products1631603Salmon pate, garlic prawns
  • All have amber lights for salt and at least one other of sugar and saturated fat
9 Fruit and vegetables1811810 -
10 Meat and meat products1681680 -
11 Non-alcoholic beverages461333Fruit flavoured teas and iced teas, matcha
  • Some teas, unlike most, carried a nutrient information panel and therefore had a HSR generated despite being low in nutrients overall
  • Iced teas with added sugar are discretionary but these teas contained fruit and in the absence of added sugar labelling it was not possible to definitively categorise these drinks as core or discretionary
  • Growth in popularity of new beverages categories (e.g., matcha, chai) suggest more classification guidance needed
12 Sauces, dressings, spreads and dips11110 -
13 Snack foods0-- -
14 Special foods75750 -
15 Sugars, honey and related products23230 -
All22192116103
TLL = Traffic Light Label, referring to the threshold set for a red traffic light under the UK nutrient profiling model.
Table 4. Discretionary products with HSR ≥ 3.5.
Table 4. Discretionary products with HSR ≥ 3.5.
Major Food Category Number of Apparent OutliersNumber of Products No Red TLLOutliers RemainingIllustrative Examples of Outliers RemainingCharacteristics of Remaining Outliers
1 Bread and bakery products16614125Sweet biscuits, savoury breads and pastries
  • Products have red TLL for sugar (sweet breads and biscuits), salt (savoury breads and biscuits) or saturated fat (puff pastries, quiche)
2 Cereal and grain products25419064Breakfast cereals, cereal and nut-based bars
  • Most have red TLL for sugar and a few salt or saturated fat
3 Confectionery17316112Jellies, cocoa powder, chocolate strawberries
  • Products have red TLL for sugar (jellies) or saturated fat (chocolate based items)
4 Convenience foods508372136Ready meals, meal kits
  • Most products have red TLL for saturated fat and/or salt
  • A smaller number have red TLL for sugar
5 Dairy1087632Rice puddings
  • All products have red TLL for sugar
6 Edible oils and oil emulsions202Almond oil, lemon butter
  • All products have red TLL for saturated fat or sugar.
7 Eggs0-- -
8 Fish and fish products21920613Salt and pepper products, fish cakes
  • All products have red TLL for salt.
9 Fruit and vegetables34726186Fruit bars and bites, pickled vegetables
  • Fruit products have red TLL for sugar (fruit bars, bites) and sometimes saturated fat (fruit bites with coconut)
  • Vegetable products have red TLL for salt (pickled vegetables, olives)
10 Meat and meat products384213171Sliced meats, frozen and chilled meats
  • Most products have red TLL for salt or saturated fat and a few for both
11 Non-alcoholic beverages30228Milk flavourings, beverages mixes
  • Products have red TLL for sugar. Are able to take advantage of ‘as prepared’ rules
12 Sauces, dressings, spreads and dips12451015230Salty dips, relishes and chutneys
  • Most products have red TLL for salt, some for sugar and a few for saturated fat
13 Snack foods652461191Potato chips, vegetable and legume-based snacks, corn chips
  • Most products have red TLL for salt, some for saturated fat, a few for sugar and a few for several
14 Special foods22- -
15 Sugars, honey and related products15105Syrups
  • Products all have red TLL for sugar
All41053130975
TLL = Traffic Light Label, referring to the threshold set for a red traffic light under the UK nutrient profiling model.
Table 5. Priority recommendations for reviewing the HSR algorithm and ADG definitions to improve alignment.
Table 5. Priority recommendations for reviewing the HSR algorithm and ADG definitions to improve alignment.
  • Review the weighting given to salt in HSR algorithm, given the large number of sauces, dips, savoury snacks, sliced meats and convenience foods that receive a high HSR despite being high in salt. This would be supported by the 2017 update of Australia’s Nutrient Reference Value for sodium.
  • Review the eligibility of fried or pickled vegetables and dried fruits for FVNL points given their receipt of high HSR scores despite being high in negative nutrients. This would be supported by references in ADG text (but not the ABS Table) that such products should be only consumed occasionally and in small amounts.
  • Review the weighting given to sugar, and/or incorporate added sugars given the large number of outliers in categories likely to contain a mix of naturally occurring and added sugars. These appeared at both ends, i.e., core yoghurts with fruit or flavours, fruit flavoured teas, as well as discretionary chutneys, breakfast cereals, muesli and fruit bars, dairy desserts and table sauces.
  • Review the ADG definition of discretionary, including additional guidance on ‘high in’ criteria for saturated fat, added sugars and salt to elucidate, for example, at what point a flavoured yoghurt can more properly be considered a dairy dessert.
  • Review a wide range of ABS table classifications (see Appendix B) including: ‘core’ status of breakfast cereals with sugar up to 30 g/100 g, cheese regardless of salt and saturated fat content, yoghurt and flavoured milks regardless of sugar or saturated fat content, most meat and fish regardless of salt content; ‘discretionary’ status of vegetable and legume based dips, ‘potato products’ and crumbed fish intended for home baking; and, appropriate treatment of growing product categories such as breakfast beverages and coconut products.
  • Once the algorithm is reviewed, make HSR mandatory to enable consumers to receive the full benefit of the system’s performance across the food supply.

© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
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