Exploring perceptions and beliefs about the cost of fruit and vegetables and whether they are barriers to higher consumption.

BACKGROUND: Fruit and vegetable (F&V) consumption is below recommendations, and cost may be a barrier to meeting recommendations. Limited evidence exists on individual perceptions about the cost, actual spending and consumption of F&V. This study investigated perceptions and beliefs about cost of F&V and whether this is a barrier to higher consumption. METHODS: An online survey of Australian adults (n = 2474) measured F&V consumption; expenditure on F&V and food; and perceived barriers to consumption. Multivariable logistic regression examined associations between participants' responses about cost of F&V and demographic factors, and with actual consumption and expenditure on F&V. RESULTS: Cost was identified as a barrier for 29% of people not meeting recommended fruit servings and for 14% of people not meeting recommendations for vegetables. Cost was a more common barrier for those on lower incomes (fruit aOR 1.89; 95% CI 1.20-2.98 and vegetables aOR 2.94; 95% CI 1.97-4.39) and less common for older participants (fruit aOR 0.33; 95% CI 0.17-0.62 and vegetables aOR 0.31; 95% CI 0.18-0.52). There was no association between the perceived barriers and actual F&V spending. Twenty percent of participants said F&V were not affordable; 39% said cost made it difficult to buy F&V, and for 23% the cost of F&V meant they bought less than desired. CONCLUSIONS: A minority reported F&V were not affordable where they shopped and that cost was a barrier to higher consumption. However, it is apparent that young adults and those on low incomes eat less than they would like because of cost. Strategies that remove financial impediments to consumption are indicated for these population sub-groups.

Advertising to children initiatives have not reduced unhealthy food advertising on Australian television.

Background: In response to rising childhood obesity rates, the Australian food industry implemented two initiatives in 2009 to reduce the marketing of unhealthy food to children. This study evaluated the efficacy of these initiatives on the rate of unhealthy food advertising to children on Australian television. Methods: The rates of food advertisements on three free-to-air commercial television channels and a youth-oriented digital channel in Sydney, Australia were analysed over 2 weekdays (16 h) and two weekend days (22 h). Advertisements were categorized according to the healthiness of foods advertised (non-core, core, miscellaneous) and signatory status to the food industry advertising initiatives. Results: Total food advertising rates for the three channels increased from 5.5/h in 2011 to 7.3/h in 2015, due to an increase of 0.8/h for both core and miscellaneous foods. The rate of non-core food advertisements in 2015 (3.1/h) was similar to 2011 (3.0/h). The youth-oriented channel had fewer total food advertisements (3.7/h versus 7.3/h) but similar fast-food advertisement rates (1.3/h versus 1.3/h). Conclusions: There was no change in the rate of unhealthy food advertising since 2011, suggesting minimal impact of the current food industry initiatives on reducing children's exposure to unhealthy food advertising.

Support for food policy initiatives is associated with knowledge of obesity-related cancer risk factors.

OBJECTIVES: To investigate community support for government-led policy initiatives to positively influence the food environment, and to identify whether there is a relationship between support for food policy initiatives and awareness of the link between obesity-related lifestyle risk factors and cancer. METHODS: An online survey of knowledge of cancer risk factors and attitudes to policy initiatives that influence the food environment was completed by 2474 adults from New South Wales, Australia. The proportion of participants in support of seven food policy initiatives was quantified in relation to awareness of the link between obesity, poor diet, insufficient fruit and vegetable consumption, and physical inactivity with cancer and other health conditions. RESULTS: Overall, policies that involved taxing unhealthy foods received the least support (41.5%). Support was highest for introducing a colour-coded food labelling system (85.9%), restricting claims being made about the health benefits of foods which are, overall, unhealthy (82.6%), displaying health warning labels on unhealthy foods (78.7%) and banning unhealthy food advertising that targets children (72.6%). Participants who were aware that obesity-related lifestyle factors are related to cancer were significantly more likely to support food policy initiatives than those who were unaware. Only 17.5% of participants were aware that obesity, poor diet, insufficient fruit and vegetable consumption, and physical inactivity are linked to cancer. CONCLUSIONS: There is strong support for all policies related to food labelling and a policy banning unhealthy food advertising to children. Support for food policy initiatives that positively influence the food environment was higher among those who were aware of the link between cancer and obesity-related lifestyle factors than among those who were unaware of this link. Increasing awareness of the link between obesity-related lifestyle factors and cancer could increase community support for food policy initiatives, which, in turn, support the population to maintain a healthy weight.

Health and nutrition content claims on Australian fast-food websites.

OBJECTIVE: To determine the extent that Australian fast-food websites contain nutrition content and health claims, and whether these claims are compliant with the new provisions of the Australia New Zealand Food Standards Code ('the Code'). DESIGN: Systematic content analysis of all web pages to identify nutrition content and health claims. Nutrition information panels were used to determine whether products with claims met Nutrient Profiling Scoring Criteria (NPSC) and qualifying criteria, and to compare them with the Code to determine compliance. SETTING: Australian websites of forty-four fast-food chains including meals, bakery, ice cream, beverage and salad chains. SUBJECTS: Any products marketed on the websites using health or nutrition content claims. RESULTS: Of the forty-four fast-food websites, twenty (45 %) had at least one claim. A total of 2094 claims were identified on 371 products, including 1515 nutrition content (72 %) and 579 health claims (28 %). Five fast-food products with health (5 %) and 157 products with nutrition content claims (43 %) did not meet the requirements of the Code to allow them to carry such claims. CONCLUSIONS: New provisions in the Code came into effect in January 2016 after a 3-year transition. Food regulatory agencies should review fast-food websites to ensure compliance with the qualifying criteria for nutrition content and health claim regulations. This would prevent consumers from viewing unhealthy foods as healthier choices. Healthy choices could be facilitated by applying NPSC to nutrition content claims. Fast-food chains should be educated on the requirements of the Code regarding claims.

Discussing alcohol and cancer with patients: Knowledge and practices of general practitioners in New South Wales and South Australia.

BACKGROUND: Alcohol is associated with several cancers; however, the Australian community has low awareness of the link between alcohol consumption and cancer. Little information exists regarding when and why general practitioners (GPs) discuss alcohol with patients. OBJECTIVE: The objective of this article is to explore GPs' attitudes and practices when discussing alcohol with patients. This includes awareness of alcohol recommendations and evidence of the alcohol-cancer link, and discussion around barriers and enablers to encouraging patients' alcohol behaviour change. RESULTS: GPs did not routinely ask patients about their alcohol consumption or advise on drinking recommendations. Many had a broad understanding of alcohol as a cancer risk factor, but knowledge of the causal mechanisms and current evidence was limited. DISCUSSION: GPs are trusted health advisers. Providing them with up-to-date evidence on the alcohol-cancer link and drinking recommendations may encourage routine patient screening of alcohol consumption and delivery of simple education on the harms of long-term drinking.

Time to address continued poor vegetable intake in Australia for prevention of chronic disease.

BACKGROUND: Australian and most international Dietary Guidelines recommend people consume more fruits and vegetables (F&V) to maintain a healthy weight and reduce chronic disease risk. Previous Australian and international surveys have shown sub-optimal consumption of F&V. OBJECTIVES: This study aimed to assess adults' F&V consumption, knowledge of recommended servings, readiness to change, barriers/enabling factors, so that this knowledge might be used for campaigns that support improved consumption. MATERIAL AND METHODS: An online survey of a representative sample of adults living in New South Wales, Australia (n = 2474) measuring self-reported F&V consumption; attitudes towards F&V consumption; stage of change for increasing F&V; barriers to consumption; and knowledge of cancer-health benefits. RESULTS: F&V consumption was below recommendations, with vegetable consumption notably low. Only 10% of participants ate at least five servings of vegetables/day (median intake was two daily servings), and 57% consumed two servings fruit/day. There was poor recognition that intake of vegetables was inadequate and this was a barrier to improving vegetable consumption; with preferences for other foods, habit and cost also important barriers. Key barriers to increasing fruit intake were habit, preferences for other foods, perishability, and cost. For vegetable consumption, 49% of participants were in the pre-contemplation stage of change, whereas for fruits 56% were in the action/maintenance stage. Sixty-four percent of respondents believed that eating F&V would protect against cancer, with 56% reporting they thought not eating enough F&V would cause cancer. IMPLICATIONS: Understanding what motivates and prevents people from consuming F&V is important for developing effective health promotion programs. Similar to previous surveys, there has been little shift in F&V consumption. Social marketing campaigns have been shown to improve health-related behaviours, and this study may assist in identifying audience segmentation for better targeted campaigns.

Sponsorship of junior sport development programs in Australia.

OBJECTIVE: This study investigated the nature and extent of unhealthy food, beverage, alcohol and gambling sponsors of children's sport development programs. METHODS: Websites of junior development sport programs (n=56) associated with sporting organisations that received funding from the Australian Sporting Commission were analysed. Sponsors were considered unhealthy if they were alcohol or gambling companies or sold food and/or beverages that failed independent nutrition criteria. The websites of the sport development programs were also analysed for types of promotion. RESULTS: There were 246 sponsors identified. Eleven (4.5%) sponsors were food, beverage, alcohol or gambling companies of which 10 (91%) were unhealthy. Surf Lifesaving (n=4) and athletics (n=3) websites had the highest number of unhealthy sponsors. Promotions associated with unhealthy sponsorship included logo placement on homepages (100%), naming rights (31%), logo on sport uniforms (27%) and branded participant packs (31%). CONCLUSIONS: The majority of food and beverage company sponsors in sport development programs are companies associated with unhealthy products. Two websites hosting junior development program information included an alcohol company sponsor and a gambling company sponsor. IMPLICATIONS: Unhealthy product sponsorship of children's sport should be addressed as part of a comprehensive regulation designed to reduce exposure to marketing of unhealthy foods.

Investigating nutrient profiling and Health Star Ratings on core dairy products in Australia.

OBJECTIVE: To determine whether the ratings from the Australian front-of-pack labelling scheme, Health Star Rating (HSR), and the ability to carry health claims using the Nutrient Profiling Scoring Criterion (NPSC) for core dairy products promote foods consistent with the Australian Dietary Guidelines. DESIGN: The Australian nutrient profiling model used for assessing eligibility for health claims was compared with the nutrient profiling model underpinning the HSR system to determine their agreement when assessing dairy products. Agreement between the extent to which products met nutrient profiling criteria and scored three stars or over using the HSR calculator was determined using Cohen's kappa tests. SETTING: The four largest supermarket chains in Sydney, Australia. SUBJECTS: All available products in the milk, hard cheese, soft cheese and yoghurt categories (n 1363) were surveyed in March-May 2014. Nutrition composition and ingredients lists were recorded for each product. RESULTS: There was 'good' agreement between NPSC and HSR overall (κ=0·78; 95 % CI 0·75, 0·81; P<0·001), for hard cheeses (κ=0·72; 95 % CI 0·65, 0·79; P<0·001) and yoghurt (κ=0·79; 95 % CI 0·73, 0·86; P<0·001). There was 'fair' agreement for milk (κ=0·33; 95 % CI 0·20, 0·45; P<0·001) and 'very good' agreement for soft cheese (κ=0·84; 95 % CI 0·75, 0·92; P<0·001). Generally, products tended to have HSR consistent with other products of a similar type within their categories. CONCLUSIONS: For dairy products, the HSR scheme largely aligned with the NPSC used for determining eligibility for health claims. Both systems appeared be consistent with the Australian Dietary Guidelines for dairy products, with lower-fat products rating higher.

Variations in serving sizes of Australian snack foods and confectionery.

This study examined the serving size and energy content per serving of Australian packaged snack foods and confectionery products. Nutrition Information Panel data for 23 sub-categories of packaged snack foods (n = 3481) were extracted from The George Institute for Global Health's 2013 branded food composition database. Variations in serving size and energy content per serving were examined. Energy contents per serving were compared to recommendations in the Australian Dietary Guidelines. Serving sizes varied within and between snack food categories. Mean energy content per serving varied from 320 kJ to 899 kJ. More energy per serving than the recommended 600 kJ was displayed by 22% (n = 539) of snack foods classified in the Australian Dietary Guidelines as discretionary foods. The recommendation for energy content per serving was exceeded in 60% (n = 635) of snack foods from the Five Food Groups. Only 37% (n = 377) of confectionery products displayed the industry-agreed serving size of 25 g. Energy content per serving of many packaged snack foods do not align with the Australian Dietary Guidelines and the industry agreed serving size has not been taken up widely within the confectionery category. Given the inconsistencies in serving sizes, featuring serving size in front-of-pack information may hinder the objective of a clear and simple nutrition message. Messaging to help consumers make healthier choices should consider the variation in serving sizes on packaged snack foods.

The availability and accessibility of nutrition information in fast food outlets in five states post-menu labelling legislation in New South Wales.

OBJECTIVES: 1) Explore the availability and accessibility of fast food energy and nutrient information post-NSW menu labelling legislation in states with and without menu labelling legislation. 2) Determine whether availability and accessibility differed compared with pre-menu labelling legislation in NSW. METHODS: We visited 210 outlets of the five largest fast food chains in five Australian states to observe the availability and accessibility of energy and nutrient information. Results were compared with 197 outlets surveyed pre-menu labelling. RESULTS: Most outlets (95%) provided energy values, half provided nutrient values and 3% provided information for all menu items. The total amount of information available increased post-NSW menu labelling implementation (473 versus 178 pre-implementation, p<0.001); however, fewer outlets provided nutrient values (26% versus 97% pre-implementation, p<0.001). CONCLUSIONS: Fast food chains surveyed had voluntarily introduced menu labelling nationally. However, more nutrient information was available in-store in 2010, showing that fast food chains are able to provide comprehensive nutrition information, yet they have stopped doing so. IMPLICATIONS: Menu labelling legislation should compel fast food chains to provide accessible nutrition information including nutrient values in addition to energy for all menu items in-store. Additionally, public education campaigns are needed to ensure customers can use menu labelling.

Energy-dense fast food products cost less: an observational study of the energy density and energy cost of Australian fast foods.

OBJECTIVE: To examine the association between energy cost and energy density of fast food products. METHODS: Twenty Sydney outlets of the five largest fast food chains were surveyed four times. Price and kilojoule data were collected for all limited-time-only menu items (n=54) and a sample of standard items (n=67). Energy cost ($/kilojoule) and energy density (kilojoules/gram) of menu items were calculated. RESULTS: There was a significant inverse relationship between menu item energy density and energy cost (p<0.001). Salads had the highest energy cost, while value items, meals that included a dessert and family meals had the lowest. CONCLUSIONS: Fast food chains could provide a wider range of affordable, lower-energy foods, use proportional pricing of larger serve sizes, or change defaults in meals to healthier options. More research is required to determine the most effective strategy to reduce the negative impact of fast food on the population's diet. IMPLICATIONS: Current pricing in the fast food environment may encourage unhealthier purchases.

Investigating fruit and vegetable claims on Australian food packages.

OBJECTIVES: Fruit and vegetable claims on food packages are not regulated under Australian food standards. The present study aimed to: (i) investigate the number and healthiness of products carrying fruit and vegetable claims in Australia; and (ii) compare the nutrition composition of these products with fresh fruit and/or vegetables. DESIGN: Content analysis of fruit and vegetable claims on food packages. The Australian food standards nutrient profiling model was used to determine the proportion of products not meeting nutrient profiling criteria. The nutrient composition of products carrying claims referencing the servings of fruit and vegetables in the product were compared with that of the dominant fruit and/or vegetables in each product. SETTING: The five largest supermarket chains in Australia. SUBJECTS: All available products in the fruit snacks, soups and fruit and vegetable juices/fruit drinks categories (n 762) were surveyed. Nutrition composition, ingredients and claims were recorded for each product. RESULTS: Of the products surveyed, 48 % (n 366) carried at least one claim, of which 34 % (n 124) did not meet nutrient profiling. Products carrying claims referencing the number of servings of fruit and vegetables had more energy, sodium, saturated fat and sugar, and less fibre, than fresh fruit and/or vegetables (all P<0·001). CONCLUSIONS: Many products carried fruit and vegetable claims and were significantly higher in energy, saturated fat, sugars and sodium than fresh fruit and vegetables. Marketing these products as a way of meeting fruit and vegetable intake is inaccurate and potentially misleading. Fruit and vegetable claims should be regulated using nutrient profiling.

The effect of energy and traffic light labelling on parent and child fast food selection: a randomised controlled trial.

OBJECTIVES: Labelling of food from fast food restaurants at point-of-purchase has been suggested as one strategy to reduce population energy consumption and contribute to reductions in obesity prevalence. The aim of this study was to examine the effects of energy and single traffic light labelling systems on the energy content of child and adult intended food purchases. PARTICIPANTS AND METHODS: The study employed a randomised controlled trial design. English speaking parents of children aged between three and 12 years were recruited from an existing research cohort. Participants were mailed one of three hypothetical fast food menus. Menus differed in their labelling technique ­ either energy labels, single traffic light labels, or a no-label control. Participants then completed a telephone survey which assessed intended food purchases for both adult and child. The primary trial outcome was total energy of intended food purchase. RESULTS: A total of 329 participants completed the follow-up telephone interview. Eighty-two percent of the energy labelling group and 96% of the single traffic light labelling group reported noticing labelling information on their menu. There were no significant differences in total energy of intended purchases of parents, or intended purchases made by parents for children, between the menu labelling groups, or between menu labelling groups by socio-demographic subgroups. CONCLUSIONS: This study provided no evidence to suggest that energy labelling or single traffic light labelling alone were effective in reducing the energy of fast food items selected from hypothetical fast food menus for purchase. Additional complementary public health initiatives promoting the consumption of healthier foods identified by labelling, and which target other key drivers of menu item selection in this setting may be required.

Regulating health claims on food labels using nutrient profiling: what will the proposed standard mean in the Australian supermarket?

OBJECTIVE: Proposed Australian regulation of claims on food labels includes requirements for products carrying a health claim to meet nutrient profiling criteria. This would not apply to nutrition content claims. The present study investigated the number and healthiness of products carrying claims and the impact of the proposed regulation. DESIGN: Observational survey of claims on food packages across three categories: non-alcoholic beverages, breakfast cereals and cereal bars. Nutrient profiling was applied to products carrying claims to determine their eligibility to carry health claims under the proposed regulation. SETTING: Three large metropolitan stores from the three major supermarket chains in Sydney, Australia were surveyed in August 2011. SUBJECTS: All claims on 1028 products were recorded. Nutrition composition and ingredients were collected from the packaging, enabling nutrient profiling. The proportion of products in each category carrying claims and the proportion of these that did not meet the nutrient profiling criteria were calculated. RESULTS: Two-thirds of products in the three categories (ranging from 18 to 78 %) carried at least one claim. Of those carrying health claims, 31 % did not meet the nutrient profiling criteria. These would be ineligible to carry these claims under the proposed regulation. Additionally, 29 % of products carrying nutrition content claims did not meet the nutrient profiling criteria. CONCLUSIONS: The number of products carrying nutrition content claims that did not meet the nutrient profiling criteria suggests that comprehensive regulation is warranted. Promotion of unhealthy foods using claims is potentially misleading for consumers and hinders their ability to select healthier foods. Implementation of the proposed regulation represents an improvement to current practice.

Sales of healthy choices at fast food restaurants in Australia.

OBJECTIVE: Some fast food chains have introduced healthier options, however sales data for these menu items are not publicly available. This study aimed to observe healthy and unhealthy meal purchases in Australian fast food stores. METHODS: An observational study was conducted comparing the purchases of healthy and unhealthy meals at 20 McDonald's stores in a variety of socio-economic areas in New South Wales, Australia. Data collection occurred at lunch and dinner times over a two-week period that included both the school holidays and term time. Purchases of Heart Foundation Tick Approved (healthy), standard menu items (unhealthy) and take-away meals (healthfulness unobservable due to take-away bags) were recorded. Chi-square and Fisher's Exact Tests were used to assess differences in purchases. RESULTS: There were 1,449 meal purchases observed, of which 1% were healthy, 65% were unhealthy and 34% were take-away. There were no statistically significant differences in the purchases of healthy meals by socioeconomic status area, weekdays compared to weekends, school term compared to school holidays, or at lunch compared to dinner time. CONCLUSIONS: Although the provision of healthy fast food options is commendable, this research shows that only a minority of Australians are purchasing them.

Fries or a fruit bag? Investigating the nutritional composition of fast food children's meals.

The impact of children's fast food meals on their daily nutritional requirements has not been assessed in Australia. Analysis of the nutritional composition of children's meals from six fast food chains was conducted. The energy, saturated fat, sugar and sodium content of all children's meals from the chains were assessed against the fast food industry-defined nutrient criteria for healthy meals and children's recommended daily nutritional requirements, as defined by the Nutrient Reference Values and the Dietary Guidelines for Children and Adolescents in Australia. Overall children's fast food meals are high in saturated fat, sugar and sodium. Only 16% and 22% of meals met the industry's nutrient criteria for children aged 4-8 and 9-13 years, respectively. Seventy-two percent of fast food meals exceeded 30% of the daily energy recommendations for 4 year old children, and 90% of meals exceeded 30% of the upper limit for sodium for children aged 4-8. Some meals also exceeded the upper limit for sodium and daily saturated fat recommendations for children aged 4-8 years. Reformulation of children's meals to improve their nutritional composition and revision of the industry's nutrient criteria to align with children's dietary requirements are urgently needed.

Fast facts: The availability and accessibility of nutrition information in fast food chains.

ISSUE ADDRESSED: Nutrition information at the point-of-sale assists consumers to make informed fast food choices. This study provides a baseline measure of the availability and accessibility of nutrition information in fast food outlets in Australia, filling a gap in the literature. METHODS: An in-store observational survey was conducted in 222 outlets of five fast food chains in five states. The Australian websites for each chain were surveyed for nutrition information. RESULTS: At least some nutrition information was available in 66% of outlets. The availability of information was higher in lower socioeconomic areas. Significantly less information was available in signatory chains of the self-regulatory marketing code. Information provided was generally incomplete; only one outlet (0.5%) provided information for all food and beverage items. In some instances information was old. Information was more available for 'healthier' products and less available for meal combinations. Information was provided on all chains' websites, however it was sometimes difficult to locate. CONCLUSIONS: While most outlets surveyed made some nutrition information available to consumers, it was generally incomplete. Fast food chains should provide comprehensive, up-to-date information for all menu items. Chains should also ensure their staff members are adequately trained in providing nutrition information.