Discretionary choices are defined as foods and drinks “not needed to meet nutrient requirements and do not fit into the Five Food Groups… when consumed sometimes or in small amounts, these foods and drinks contribute to the overall enjoyment of eating” [1
]. Discretionary choices include subgroups of foods and drinks higher in saturated fat, added sugar and/or salt such as cakes, muffins and slices, sweet biscuits (cookies), chocolate, sugar-sweetened drinks, processed meats, potato crisps and similar, hot chips, and takeaway foods (i.e., burgers, pizza, pies). Excess consumption of discretionary choices, by children in Australia [2
] and other countries internationally [3
], can displace intake of food in the Five Food Groups (vegetables, fruit, whole grains, dairy, meats, and alternatives), provide excess energy intake leading to weight gain, and contribute to the development of chronic health conditions [5
Discretionary choices are higher in saturated fat, added sugars, and/or salt [1
], which can contribute to diet-related chronic diseases such as Type 2 Diabetes and cardiovascular disease [1
]. They can be energy-dense and contribute to positive energy balance and obesity in children and adolescents [7
]. Children who are overweight or obese are at least twice as likely as children of healthy weight to become overweight or obese as adults [9
]. The associated negative health effects of overconsumption of energy, saturated fat, added sugars, and salt seen in adults can emerge earlier in life, including insulin resistance, elevated blood cholesterol levels, and elevated blood pressure [8
]. Further, eating habits and food preferences are established early in life, and tend to track into adulthood [10
]. Establishing healthy eating habits early can reduce the risk of obesity and diet-related chronic disease across the lifespan. Understanding the contribution of discretionary choices to the intake of energy, saturated fat, added sugars, and salt will enable the identification of targets to focus efforts in children and adolescents to improve population nutrient intakes, diet quality, and health.
In the most recent Australian Health Survey, 27% of 5–17 year old children were overweight or obese [11
], a rate similar to, or exceeding those found in other countries [12
]. A comparison of intake of discretionary choices by Australian children aged 2–16 years from 1995 to 2007 by Rangan et al. [15
] found that despite a slight decrease in energy intake coming from discretionary foods and drinks (40% vs. 35%), intake considerably exceeded recommendations (0–3 serves, or 0–1800 kJ, depending on age, height, and activity level) [7
]. Preliminary analyses of the Australian Health Survey data show that 99% of children and adolescents continue to exceed recommendations for discretionary choice intake [11
]. No direct comparisons across countries are available given the varying terminology and classifications of discretionary choices, yet studies in the United States and Mexico have reported between 27–30% of children and adolescents total energy intake derived from several subgroups of discretionary choices [3
This study uses data from the 2011–2012 National Nutrition and Physical Activity Survey (NNPAS) to examine the contribution of energy, saturated fat, added sugars and sodium from discretionary foods and drinks to overall energy intake in Australian children and adolescents. This work updates and builds on the findings of Rangan et al. [15
], which described the contribution of discretionary choices to energy intake in a similar population, but did not report the contribution of saturated fat, added sugars and sodium from these foods and drinks to the diet. By considering these nutrients (saturated fat, added sugar, and sodium) in addition to energy, this study will be able to identify targets for dietary modification that can have the greatest impact on population intakes, for both obesity and chronic disease prevention. Thus, the aim of this study was to determine the main discretionary choice subgroups that are contributing to energy and key nutrient intakes in children aged 2–18 years, to identify discretionary choice subgroup targets for intervention. A secondary aim was to compare key food/drink contributors to energy and key nutrient targets across age groups in consumers of discretionary choices.
This analysis of a nationally representative sample of Australian 2–18 year olds describes the specific discretionary food and beverage groups that contribute most to total energy, saturated fat, sodium, and added sugars intakes. Cakes and biscuits, cereal-based takeaway foods, dishes containing processed meats, and sugary drinks were relatively commonly consumed and were within the top three to five sources of energy, saturated fat, sodium, and/or added sugars. While some minor differences were observed by age group sub-categories, cakes and biscuits were ubiquitous in their contribution to dietary intake across age group categories. Reducing the intake of selected discretionary choices, such as cakes and biscuits, is likely to provide the biggest impact across multiple dietary components.
Discretionary choices are a heterogenous collection of foods and drinks that are not needed to meet nutrient requirements, and are associated with higher intakes of energy and nutrients that increase risk of obesity and multiple chronic diseases [1
]. Children’s overall discretionary choices intake may be high in energy, saturated fat, sodium, or added sugars, but subgroups of discretionary choices are not necessarily high across each of these dietary targets. The novelty of the present analysis is in consideration of multi-nutrient analysis; by identifying top contributors across the dietary factors of concern, selected discretionary choice subgroups may be prioritized for nutrition messages. Focusing interventions on a targeted group of discretionary choices may deliver the best impact on population nutrient intakes, diet quality and health.
Cakes and biscuits, and processed meats (and to a lesser extent cereal-based takeaway foods) were commonly consumed and were top contributors to dietary factors of concern. Collectively, all sugar-sweetened drinks (i.e., cordials, fruit juice drinks and soft drinks, energy and sports drinks) were also commonly consumed, were the top contributor to added sugars, and contributed a combined 4.4% to total energy intake. In contrast, cakes, muffins, and slices alone contributed 4.2% to total energy intake. Similar patterns were generally observed across the per capita, per consumer, and plausible reporter analyses. Targeting reductions in intakes of these five (of 19) (cakes, muffins and slices; sweet biscuits; processed meats; cereal-based takeaway foods; and, sugar-sweetened drinks (including fruit drinks and cordials) groups of discretionary foods and drinks would appear to have the biggest impact across total energy intake, as well as saturated fat, sodium, and added sugars intakes. Targeting consumers of these discretionary choices is likely to achieve a significant overall population impact.
The analysis by age group categories revealed small differences in patterns between younger and older children; however the same food groups remained broadly the top contributors to energy and nutrient intakes. While intake trends increased across the age groups, this is likely to reflect increased requirements with growth. Focusing on the percent of total intake, the trends were similar across age groups, perhaps except for sugar-sweetened soft drinks and cereal-based takeaway foods. Cakes and biscuits, processed meats, butter and dairy fats, and fruit drinks were commonly consumed in the 2–3 year old group. Consumption patterns for commonly consumed discretionary choices are evident from a young age and are relatively stable across the age group categories. The higher total discretionary choice intake in older children and adolescents reflects stable trends in key discretionary choices (such as cakes and biscuits), plus the introduction of additional subgroups (e.g., soft drinks, chocolate and fried potatoes) during adolescence.
This study utilizes similar methodology to Rangan et al. [15
], which describes intake of ‘extra’ foods in Australian 2–16 year olds in 1995 and 2007. There are differences with the present analyses in terms of the definition of ‘extra’ versus ‘discretionary’ choices (reflecting changes in dietary guidelines between 2003 [25
] and 2013 [1
]), the age range of the sample analyzed, and other variances in survey methodology preventing direct comparison to Rangan et al. [19
]. However, the percent of total energy intake from cakes, muffins, and slices is higher in 2011–2012 (i.e., this study) compared to 2007 sample (4.2% vs. 2.9%) [15
]. Percent of energy derived from fried potato is slightly lower (2.5% in 2011–2012 vs. 2.9% in 2007), whereas the contribution to total energy intake of sweet biscuits has slightly increased (2.9% vs. 2.5%), and potato crisps (2.7% vs. 2.6%) have remained the same [15
]. Processed meats were not classified as ‘extra’ foods in the previous analysis. In the present survey, these subgroups contributed 5.2% and 10.7% of total energy and sodium intake, respectively. Importantly, in the present analysis, contribution to saturated fat, sodium and added sugars intake are described enabling interpretation beyond gram and energy intake. Children’s intake of discretionary choices remains well above recommended intakes, with little qualitative change being observed since 2007. Interventions are urgently needed that achieve reductions in the intake of discretionary choices. The benefit of targeting the discretionary choices highlighted in this analyses, is that there is likely to be benefit in terms of reduced risk of positive energy balance and risk of obesity, together with risk factor reduction supporting the prevention of conditions, such as diabetes, dental caries, hypertension, and cardiovascular disease.
There remain few international studies that examine contemporary consumption patterns of discretionary-type foods and drinks, particularly in the context of considering energy intake and multiple nutrients of concern [26
]. In a United States (U.S.) study using data from the 2003–2006 National Health and Nutrition Examination Survey (NHANES), cake/cookies/pastry-type foods were a top ranked source of total energy intake and soft drinks/soda and candy/sugar/sugary foods were the top two sources of added sugars in 2–18 year olds [3
]. Another U.S. study, using this same data, identified overlap between major sources of energy and ‘empty calories’ including soda, grain desserts and pizza [29
]. Cakes, cookies, desserts, as well as sugary drinks and savory snacks, were major sources of energy intake in a nationwide survey of Brazilians (10 years and older) [26
]. The findings from the present study show cakes and biscuits and sugary drinks as top contributors to total energy and added sugars intake, but also highlight that cakes and biscuits and additional groups, such as processed meats and cereal-based takeaway foods, further make a significant contribution to energy, saturated fat, sodium, and added sugars intake.
With an understanding of key discretionary food and beverage targets, the dietary strategies that can be leveraged to reduce children’s discretionary choice intake can be considered. For example, Van de Bend et al. [30
] describe the changes in portion sizes between the 2007 and 2011–2012 Australian Health Surveys. Between these years, the portion size of processed meats, such as sausages, increased, while the portion sizes of many energy-dense packaged snack foods has remained stable (e.g., muesli bars, potato crisps, chocolate) or increased (e.g., meat-based dishes and cakes) [30
]. Interventions to reduce discretionary choice portion size, such as downsizing serving sizes of packaged foods, are important but will require further focus beyond efforts to date [31
]. Dietary strategies, such as reducing the frequency of consumption of discretionary choices or via substitution to choices within the five food groups, are warranted [32
]. Recent modelling in adults has shown substitution to be useful [33
], perhaps signaling a revisit of a swap-it type campaign drawing on the stronger evidence base now available [34
]. The multi-strategy approach of the Australian Healthy Food Partnership [35
] is important, with the moderation of portion size, substitution for healthy foods, and to a lesser degree reformulation of discretionary choices are all important strategies to leverage. Reformulation may have a role to play in reducing added sugars, sodium, and saturated fat intakes, but has limits in its food science technology to manipulate energy density [33
]. Interventions spanning the socio-ecological model, for example, the food supply, food availability, and importantly, social norms, will be needed to address these key targets [36
This secondary analysis of Australia’s most contemporary national nutrition survey data has some strengths and limitations. The strengths include analysis applying population weighted food intake to account for location, age, and gender. The survey under represents Friday and Saturday intakes, which may mean that discretionary choices intake is underreported across the population. This was the same in previous surveys. Categorization was based on the ABS discretionary choices flag, which while having some anomalies, enables comparison with ABS data and other studies using the same flag. The analysis utilized the definition of discretionary choices that were reflected in the current 2013 Australian Dietary Guidelines [1
]. Limitations include those that were related to the methodology of the National Nutrition and Physical Activity Survey dataset, including the use of 24 h dietary recalls [17
]. Misreporting including both under- and over-reporters was considered in conducting a sensitivity analysis excluding implausible reporters identified based on the Goldberg method [23
]. This has been presented as a supplementary analysis given misreporting within plausible energy intakes is likely and current methods do not overcome this. It is unclear if excluding implausible reporters addresses measurement bias or introduces alternative bias [22
]. Only the first 24 h recall data was used, and therefore the results reflect group patterns not necessarily usual intake. This is not an issue in our analysis as no comparisons with reference values were undertaken. While longitudinal analysis to formally evaluate changes in consumption patterns as compared to 1995 and 2007 survey data would be ideal, lack of resources and issues with differences in survey methodology (question validity) prevent this at the current time.