The Health Star Rating system - is its reductionist (nutrient) approach a benefit or risk for tackling dietary risk factors?

Comparing product healthiness according to the Health Star Rating and the NOVA classification system and implications for food labelling systems: An analysis of 25 486 products in Australia

We investigated the extent of alignment between 'healthiness' defined by a food classification system that classifies foods and beverages primarily by their nutrient composition, the Health Star Rating (HSR) and a system that considers only the degree of processing of the product, the NOVA classification system. We used data for 25 486 products contained within the George Institute for Global Health's Australian 2022 FoodSwitch Dataset. Agreement between the two systems in the proportion of products classified as 'healthier' (HSR ≥3.5 or NOVA group 1-3) or 'less healthy' (HSR <3.5 or NOVA group 4) was assessed using the κ statistic. There was 'fair' agreement (κ = 0.30, 95%CI: 0.29-0.31) between both systems in the proportion of all products classified as healthier or less healthy. Approximately one-third (n = 8729) of all products were defined as 'discordant', including 34.3% (n = 5620) of NOVA group 4 products with HSR ≥3.5 (commonly convenience foods, sports/diet foods, meat alternatives, as well as products containing non-sugar sweeteners) and 34.1% (n = 3109) of NOVA group 1-3 products with HSR <3.5 (commonly single-ingredient foods such as sugars/syrups, full-fat dairy and products specially produced to contain no ultra-processed ingredients). Our analysis strengthens the evidence for the similarities and differences in product healthiness according to a nutrient-based classification system and a processing-based classification system. Although the systems' classifications align for the majority of food and beverage products, the discordance found for some product categories indicates potential for confusion if systems are deployed alongside each other within food policies.

Impact of front-of-pack nutrition labelling in consumer understanding and use across socio-economic status: A systematic review

An unhealthy diet is a leading contributor to the increasing burden of overweight and obesity. Front-of-pack labelling (FOPL) is being recognized as a policy strategy to promote healthier choices yet there is limited evaluation of FOPL to suggest if it is effective for all population subgroups. This systematic review aimed to assess the impact of FOPL on consumer understanding and usage across socio-economic gradients. Six electronic databases were searched through a systematic search process using key terms for FOPL and socioeconomic status (SES) from 2011 to March 2022 to include studies evaluating the effectiveness of FOPL. A narrative synthesis was conducted and the results were assessed according to the effects of FOPL on consumer awareness, understanding, and usage across SES. The review included 36 articles. In general, people of all SES groups were aware of and more likely to pay attention towards FOPL than the nutrition information panel provided on the back of the package. However, the understanding and usage were relatively poor, particularly in low SES groups. While studies conducted in low SES populations suggest FOPL increased the purchase intention of healthy products, the stratified analysis across SES showed less beneficial effects in low SES individuals. The findings highlight simplified and easy-to-understand FOPLs such as Nutri-score and traffic light labelling are likely to be effective for all populations including low SES groups. Overall, the review suggests FOPLs are more visible than the nutrition information panel and may guide healthier food choices for people of all SES backgrounds. It is unclear whether FOPL influences actual purchasing and food intake as there are insufficient studies comparing the effects among higher and lower SES populations.

Warning labels and interpretive nutrition labels: Impact on substitution between sugar and artificially sweetened beverages, juice and water in a real-world selection task

Effective strategies to reduce free sugar intake are needed. This study examined exposure to a warning label, independently and in conjunction with a Health Star Rating (HSR) label, on the selection of commercially available cold beverages with real decision-making stakes. Participants (N = 511, 47.9% female, mean = 21.7 (SD = 6.1) years) accessed an online convenience store app via an on-campus laptop to select one of 10 beverages (5 sugar-sweetened beverages [SSBs], 1100% fruit juice, 2 artificially sweetened beverages [ASBs] and 2 waters). The task was repeated with the addition of a warning label on high-sugar drinks in Round 2, and the addition of an HSR label on all drinks in Round 3. Participants were informed that they would receive a complementary drink (valued at <$5AUD) based on their selections following the completion of a brief questionnaire. Baseline results indicated that SSBs and waters were the most and least popular choices, respectively. For both males and females, there was a significant decrease in SSB selection (p < 0.001) and significant increase in ASB and water selection (p < 0.001) following the addition of warning labels to high-sugar drinks. The decreased selection of SSBs and increased selection of waters was maintained in Round 3 when HSR labels were added to all drinks. 100% fruit juice selection decreased with the addition of a warning label for females only (p < 0.01), but increased following the addition of a 4-star HSR label, for both males (p < 0.05) and females (p < 0.001). Warning labels reduced young adults' selection of SSBs and promoted substitution to water. The HSR reinforced this effect for the least healthy drinks. Increased water selection may be further enhanced by ensuring that warning label thresholds and HSR algorithms align to present consistent messaging.

Empirico-inductive and/or hypothetico-deductive methods in food science and nutrition research: which one to favor for a better global health?

Scientific research generally follows two main methods: empirico-inductive (EI), gathering scattered, real-world qualitative/quantitative data to elaborate holistic theories, and the hypothetico-deductive (HD) approach, testing the validity of hypothesized theory in specific conditions, generally according to reductionist methodologies or designs, with the risk of over simplifying the initial complexity empirically perceived in its holistic view. However, in current food and nutrition research, new hypotheses are often elaborated from reductionist data obtained with the HD approach, and aggregated to form (ultra)reductionist theories, with no application of EI observations, limiting the applicability of these hypotheses in real life. This trend and the application of the EI method are illustrated as regards with the global health issue through the examples of food classifications/scoring, clinical studies, the definition of a sustainable diet, the "matrix effect"-related hypothesis, the concept of healthy core metabolism, and obesity prevention within the perspective of social sciences. To be efficient for producing food and nutritional data appropriable by the society, it finally appears that not only both approaches are necessary, starting with the EI method then the HD one, but also a back and forth between the two, this being not always realized, potentially leading to confusion and misunderstanding in society.

The impact of the nutri-score on food choice: A choice experiment in a Dutch supermarket

Front-of-package (FOP) nutrition labels are placed on products to help consumers make healthy food choices. A lab-in-field experiment was conducted to test the effectiveness of two FOP labels in promoting healthy food choices among Dutch consumers, and to examine whether dieters and health conscious shoppers are more likely to use the FOP labels. In addition, it was examined whether the placement of relatively "good" FOP label scores on products might inadvertently lead to increases in serving sizes. Participants (N = 300) consisted of Dutch consumers shopping for groceries in a local supermarket. They were randomly assigned to one of three conditions (Nutri-score, Multiple Traffic Light (MTL) label, or no label control condition), presented with six different (labeled) cereals, and asked to make a choice. Next, participants were shown a product with a relatively good label score and selected their desired serving size. The results show that the Nutri-score promotes choice of the healthiest cereal. Dieting behaviour and health conscious shopping did not moderate this effect, and the labels did not affect serving size selection. Overall, the study provides evidence for the Nutri-score to promote healthy food choices among Dutch consumers.

Australian Consumers Are Willing to Pay for the Health Star Rating Front-of-Pack Nutrition Label

The Australia and New Zealand Ministerial Forum on Food Regulation has supported the recommendations set out in the 2019 Health Star Rating System Five Year Review Report. Specifically, the forum supported, in principle, Recommendation 9, to mandate the Health Star Rating if clear uptake targets were not achieved while the system is voluntary. Given that mandatory labelling is being considered, it is important to investigate how much consumers value the Health Star Rating in order to understand potential consumer uptake and inform industry. The aim of this study was to assess consumers' valuation of the Health Star Rating system by analysing their willingness to pay for a packaged food product with the Health Star Rating label, utilising a double-bounded dichotomous choice contingent valuation approach. The results indicate that almost two-thirds of Australian household grocery shoppers were willing to pay more for a product with the Health Star Rating, on average up to an additional 3.7% of the price of the product. However, public health nutrition benefits associated with consumers' willingness to pay more for products with the Health Star Rating is currently limited by the lack of guarantee of the systems' accuracy. Given consumer support, a well validated and comprehensive Health Star Rating labelling system can potentially improve health outcomes, cost effectiveness and reduce environmental impacts.

Uptake of Australia's Health Star Rating System 2014-2019

In June 2014, Australia and New Zealand adopted a voluntary front-of-pack nutrition label, the Health Star Rating (HSR) system. Our aim was to assess its uptake in Australia in the five years following adoption and examine the feasibility of proposed targets for future uptake. Numbers and proportions of products eligible to carry a HSR were recorded each year between 2014 and 2019 as part of an annual survey of four large Australian retail outlets. Uptake was projected to 2024. 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, by manufacturer and manufacturer group. Differences in mean HSR were assessed by independent samples t-test. HSR uptake continues to increase, appearing on 7118/17,477 (40.7%) of eligible products in 2019. Voluntary display of the HSR logo was increasing linearly at 6.8% annually. This would need to be maintained to reach 70% by 2024. Of those products displaying a HSR logo, more than three quarters (76.4%) had a HSR ≥ 3.0. Products displaying a HSR logo had a significantly higher mean HSR (3.4), compared to products not displaying a HSR logo (2.6) (p < 0.001). One hundred and thirty-nine manufacturers were using HSR, but retailers Coles, Woolworths and ALDI were together responsible for the majority of uptake (55.9%). Manufacturer members of the Australian Food and Grocery Council were responsible for 28.6% of uptake. Our findings illustrate the limits of commercial goodwill in applying HSR voluntarily. Ongoing implementation must pair clear targets and timelines for uptake with a firm pathway to make HSR mandatory if sufficient progress is not achieved.

The nutritional quality of supermarket own brand chilled convenience foods: an Australian cross-sectional study reveals limitations of the Health Star Rating

OBJECTIVE

To assess the nutritional quality of Australian supermarket own brand chilled convenience foods (SOBCCF), for example, ready meals, pizza, pies and desserts.

DESIGN

Cross-sectional.

SETTING

Two large supermarkets (Coles and Woolworths) in Perth, Western Australia were audited in February 2017.

PARTICIPANTS

Data were extracted from photographic images of 291 SOBCCF, including front-of-pack information (i.e. product name, description and nutrition labels including Health Star Rating (HSR)) and back-of-pack information (i.e. nutrition information panel and ingredients list). SOBCCF were classified as healthy or unhealthy consistent with principles of the Australian Guide to Healthy Eating (AGTHE), NOVA classification of level of food processing and HSR score.

RESULTS

Fifty-four percentage of SOBCCF were classified as unhealthy according to AGTHE principles, 94 % were ultra-processed foods using NOVA and 81 % scored a HSR of ≥2·5, implying that they were a healthy choice. Some convenience food groups comprised more healthy choices overall including prepared vegetables, salad kits and bowls, soups and vegetarian food. A significantly larger proportion of SOBCCF from Coles were classified as unhealthy compared with Woolworths (70 v. 44 %, P < 0·05) using the AGTHE.

CONCLUSIONS

The findings suggest there is potential for Australian supermarkets to improve the nutritional quality of their SOBCCF and highlights the differences between supermarkets in applying their corporate social responsibility policies. Policies to assist consumers to select healthier foods should address difficulties in identifying healthy convenience foods. The findings reveal misclassification of unhealthy SOBCCF as healthy by the HSR suggesting that its algorithm should be reformed to align with recommendations of the AGTHE.

A comparison of the nutritional quality of products offered by the top packaged food and beverage companies in Canada

BACKGROUND

Canada's food supply is abundant in less healthy products, increasing Canadians' risk of obesity and non-communicable diseases. Food companies strongly influence the food supply; however, no studies have examined differences in the healthfulness of products offered by various companies in Canada. This study aimed to compare the nutritional quality of products offered by the top packaged food and beverage companies in Canada.

METHODS

Twenty-two top packaged food and beverage manufacturing companies were selected, representing > 50% of the Canadian market share in 2018. Nutritional information for products (n = 8277) was sourced from the University of Toronto Food Label Information Program 2017 database. Descriptive analyses examined the nutritional quality of products based on: 1) the Health Star Rating (HSR) system; 2) calories, sodium, saturated fat and total sugars per 100 g (or mL) and per reference amounts (RAs) defined by Health Canada; and 3) "high in" thresholds for sodium, saturated fat and total sugars proposed by Health Canada for pending front-of-package labelling regulations. Kruskal-Wallis tests compared HSRs of products between companies.

RESULTS

Mean HSRs of companies' total product offerings ranged from 1.9 to 3.6 (out of 5.0). Differences in HSRs of products between companies were significant overall and for 19 of 22 food categories (P < 0.05), particularly for fats/oils and beverages. Calories, sodium, saturated fat and total sugars contents varied widely between companies for several food categories, and depending on whether they were examined per 100 g (or mL) or RA. Additionally, 66.4% of all products exceeded ≥1 of Health Canada's "high in" thresholds for sodium (31.7%), saturated fat (28.3%) and/or sugars (28.4%). The proportion of products offered by a company that exceeded at least one of these thresholds ranged from 38.5 to 97.5%.

CONCLUSIONS

The nutritional quality of products offered by leading packaged food and beverage manufacturers in Canada differs significantly overall and by food category, with many products considered less healthy according to multiple nutrient profiling methods. Variation within food categories illustrates the need and potential for companies to improve the healthfulness of their products. Identifying companies that offer less healthy products compared with others in Canada may help prompt reformulation.