Strengthening law’s role in improving Australia’s diet

Food_Governance_Conference

Alexandra Jones and Belinda Reeve

This post originally appeared in MJA Insight and is re-posted with the MJA’s kind permission. The original article can be found at this link.

THE law can be a powerful tool for improving population health, but remains underutilised in addressing Australia’s huge burden of diet-related disease.

Taken in a broad sense, the law includes legally binding rules found in constitutions, statutes (or legislation), regulations, and other executive instruments, international treaties, and cases decided by the courts. It also includes the public institutions responsible for creating, implementing and interpreting the law.

Countries around the world are using law in innovative ways to improve nutrition, with a growing body of evidence demonstrating their effectiveness. Many of these innovations will be discussed when experts in the field gather at the University of Sydney’s Law School from 3 to 5 July for the 2nd Food Governance Conference. The conference will explore how law, policy and regulation address food system challenges or contribute to them at the local, national and global levels. The conference opens with a free public oration on Wednesday 3 July from Hilal Elver, the United Nations Special Rapporteur on the Right to Food.

To tackle high rates of obesity and sugary drink consumption, Mexico introduced a 10% tax on sugar-sweetened beverages in 2014. Evaluations of the tax found a 5.5% decline in the purchase of taxed beverages in the first year after its introduction, and a 9.7% decline in the second year. Over 40 countries have now introduced similar taxes on sugary drinks, with more likely to follow suit.

One of the most straightforward measures for improving dietary health is removing industrially produced trans fats from the food supply. Trans fat bans have been introduced by countries such as Denmark, Singapore and Switzerland, and research demonstrates these bans have virtually eliminated trans fats from the food supply. They are also more effective than voluntary measures in reducing trans fat levels in food.

The success of trans fats bans has prompted calls for similar laws to be used for nutrients such as sugar and salt, with South Africa and Argentina taking the lead on setting mandatory limits for salt in a range of commonly consumed foods. Saudi Arabia has recently announced its intention to set similar maximums for added sugar.

It’s not just national governments that are taking legislative action on dietary health. Legal innovations are taking place at the local and global levels.

Local or municipal governments often lead the way with laws or regulations that aim to improve nutrition. London has banned unhealthy food marketing on the underground, train, tram and bus services, following concerns about high levels of childhood obesity. New York City’s attempt to ban large servings of sugary drinks received widespread media and public attention; less well known is the Minneapolis Staple Foods Ordinance, which requires grocery stores to stock a minimum number of staple foods, such as fruits, vegetables and cereals.

At a global level, countries including Australia have ratified international human rights treaties that obligate them to take national action on unhealthy diets. The nature of these commitments has been explained in comments from international treaty monitoring bodies and the UN Special Rapporteurs on the Right to Food and the Right to Health. The monitoring committee for the UN Convention on the Rights of the Child, for example, has expressly called for restrictions on marketing of unhealthy food to children to protect child rights.

This last example illustrates that while legal interventions targeting the food system are important, other areas of law play a profound role in shaping the social determinants of diet-related health. Planning law can be used to ensure easy access to stores selling healthy, affordable food. Social welfare laws address barriers to food security such as poverty, poor quality housing and homelessness. Consumer protection laws shape the information environment (among other things) and provide protection against misleading and deceptive food marketing.

Australia needs strong national leadership on diet-related health, particularly considering our high levels of obesity (nearly two-thirds of adult Australians are overweight or obese) and diet-related non-communicable diseases, combined with rates of food insecurity that are unacceptably high in such a wealthy country.

Yet to date, the federal government has relied on voluntary measures and collaborative partnerships with industry to deal with issues such as marketing of unhealthy food to children, salt reduction, and the Health Star Rating front-of-pack nutrition label.

Evidence shows that these initiatives tend to suffer from limited uptake by food businesses, significant weaknesses in their design and implementation, a failure to manage commercial conflicts of interest, and a lack of transparency and accountability in governance processes.

The Health Star Rating, for example, has now been in place for 5 years but appears on less than one-third of all products, mostly those that score at the upper end of its five-star scale. This limits its value in guiding consumers towards healthier choices.

The benefits of legislation, in contrast, include mandatory compliance, with legal penalties available for non-compliance, and formal, transparent processes of enactment and amendment. The law can reach entire populations and create healthier environments in a way that is significantly more difficult for voluntary measures. This is one reason why 10 countries, including recent adopters Chile, Peru, Israel, Sri Lanka and Uruguay now have mandatory front-of-pack labels.

Australian state governments have taken important steps towards improving nutrition at a population level, for example, through kilojoule information on fast food menus, and removal of sugary drinks from schools and hospitals, but there is more that could be done. For example, legislative frameworks for city planning lie within state control, but tend not to support obesity prevention objectives.

Local government action on diet-related health is also typically overlooked in thinking and decision making on nutrition policy. However, Australian local governments possess a range of functions and powers that could be used to leverage access to healthy food, particularly within a framework of supportive state legislation, and many already have in place initiatives that have an impact on nutrition, for instance, policies on community gardens and urban agriculture.

Australia is a world leader in the use of law to regulate the manufacture, sale and marketing of tobacco products, and won significant victories against tobacco manufacturers in domestic and international courts. Australia now has some of the lowest smoking rates in the world, but we lag behind in using law to improve diet-related health.

The federal Health Minister recently announced the government’s intention to develop a national preventive health strategy. This is a rare window of opportunity to bring Australia to the forefront of action on diet-related health. Legal innovations overseas demonstrate that the re-elected federal government should give serious consideration to more hard-hitting – and effective – measures on nutrition. Now more than ever we need legal change that supports Australians in living longer, healthier lives.

Alexandra Jones is a public health lawyer leading the George Institute for Global Health Food Policy Division’s program on regulatory strategies to prevent diet-related disease. Her current research interests include Australia’s front-of-pack Health Star Rating system, fiscal policies to improve diets (e.g. taxes on sugar-sweetened beverages), product reformulation, restrictions on unhealthy marketing, and the interaction of international trade law and health.

Dr Belinda Reeve is a Senior Lecturer at the University of Sydney Law School and is co-founder of the Food Governance Node at the Charles Perkins Centre. Her research interests lie in public health law, with a particular focus on the intersections between law, regulation, and non-communicable disease prevention.

Cracking the Codex: the new frontier for nutrition labelling

Alexandra Jones, Global health lawyer and PhD Candidate at The George Institute for Global Health and the University of Sydney
Dr Anne Marie Thow, Senior Lecturer in Health Policy at the University of Sydney
Dr Carmen Huckel Schneider, Senior Lecturer, Health Policy at the University of Sydney and co-lead of the Health Governance and Financing Group and the Menzies Centre for Health Policy

Food labels hit the New York Times recently when leaks from North American Free Trade Agreement negotiations suggested the US was being urged by big American food and soft-drink companies to limit the ability of the pact’s three members – Mexico, Canada and the US – to implement warning labels on unhealthy foods.

There is no escaping the health imperative here. Obesity has nearly tripled since 1975 worldwide: 41 million children under 5 are now overweight, while 1.9 billion adults are overweight or obese. Spiralling health and economic costs mean governments are turning to evidence-based policies to prevent and control diet-related diseases like obesity, heart disease, stroke, diabetes and dental caries.

Better nutrition labelling – including front-of-pack labels that interpret nutrition information through symbols, colours or words – are part of the comprehensive package recommended by the World Health Organization. Over 20 countries already have policies in place – they include the UK’s traffic lights, France’s Nutriscore, Chile’s ‘stop sign’ warnings (which Peru appears set to follow), and Australasia’s Health Star Rating.

This proliferation and diversity poses trade and commercial challenges, and calls for some degree of consistency in global approach have been made.

Cracking the Codex (Alimentarius Commission)

This is where the international food standards body – the Codex Alimentarius Commission – comes in.

A UN body created by the WHO and UN Food and Agriculture Organization, Codex has a dual mandate: to protect consumer health, and promote fair trade practices.

Codex standards and guidance are voluntary, but in practice frequently act as a touchstone for countries looking to develop national policies. As Codex enjoys recognition as an international standards setting body by the WTO, guidance it develops also has potential to show up in trade discussions around food.

In short: what happens at Codex matters for public health nutrition.

Done well, Codex could bolster countries to take action. Left unchecked, there’s a risk outcomes could deter countries’ from implementing policies desperately needed to stem the rising global tide of non-communicable diseases.

As Codex is also notoriously slow – there’ll be a general meeting 2-6 July in Rome, and a further discussion paper for feedback later this year – it’s critical that the process itself not be used as a ‘brake’ on growing global momentum to implement strong front-of-pack labels.

Time for public health to assume a seat at the Codex table

Industry Observers have been quick to jump on opportunities to provide input into new Codex work on front-of-pack labelling. The first working group included representation from 13 international organizations representing the food industry, particularly the sugar and beverages sectors. Only two consumer groups were there.

It’s now critical we ensure public health bring their perspective to the table.

What you can do:

Read our briefing note for more information, and

  • Get involved – contact your national Codex Contact Point or join an Observer organization
  • Speak up about the public health priorities, like:
    • the importance of a definition of ‘front-of-pack nutrition labelling’ that supports schemes most likely to be effective in achieving public health objectives – and not, for example, industry preferred options such as the Guideline Daily Amount that aren’t backed by evidence
    • preserving policy space for strong and innovative measures – evidence is rapidly evolving but currently suggests for informing consumers and improving diets, this may include mandatory labels that use interpretive elements like colours, symbols or words, underpinned by robust and transparent criteria for scoring foods
  • Encourage continued action at a national level – remember, nothing in the current process prevents interested countries from pursuing front-of-pack labelling

Want to read more?

 

This piece was originally posted on the PLOS Global Health Blog on 25/06/2018, and has been re-posted with author consent.

 

Consider yourself warned: Public health coming to a fast food menu near you

New York City’s Board of Health last week unanimously agreed to require ‘salt-shaker’ warning symbols on menu items with more than an entire day’s recommended limit of 2300mg of sodium. That’s around one teaspoon of salt.

Restaurants with more than 15 outlets nationally will display warnings from 1 December 2015.

Warning: the sodium (salt) content of this item is higher than the total daily recommended limit (2300 mg). High sodium intake can increase blood pressure and risk of heart disease and stroke.

Industry groups and the National Restaurant Association have been as swift in their (predictable) opposition as public health advocates have been to welcome the move. The Center for Science in the Public Interest has even begun a Pinterest board of qualifying items – a salt shaming parade of sorts.

Surrounding public debate has renewed attention on the health impact of salt. Sugar may have received more publicity of late, but population salt reduction is a World Health Organization ‘best-buy’ for public health.

Cardiovascular disease is now the world’s biggest killer, and high blood pressure the leading risk factor for these deaths. Links between salt and high blood pressure are so well established that in 2011, countries agreed to pursue a 30% relative reduction in population salt intake, aiming towards an average of less than 5 grams a day (approx. 2000mg of sodium) by 2025. In Australia, a 30% reduction could save around 3400 lives each year – that’s three times the national road toll.

Many are aware of salt’s potential harms, but it appears most people are failing to personalise their own risk – and thereby failing to modify their behaviour accordingly.

New York’s measure is built on figures that just 1 in 10 Americans are abiding by current guidelines. Most Australians aren’t aware of the daily recommended amount, yet believe their own intake of salt to be ‘about right’ (spoiler: it’s not!) People may not realise around 75% of salt intake comes from processed and restaurant foods – making it hard for even motivated individuals to reduce consumption alone, particularly without user-friendly information available on labels or menus. Ironically the source of the problem is not the salt-shaker itself. Not the one you keep at home, anyway.

Introducing a warning icon is a step in the right direction. Graphic and simple, it aligns with growing evidence from a packaging context that interpretive labelling helps consumers make healthier choices. Such measures also have broader impact by driving reformulation. If you were the maker of Jersey Mike’s Buffalo Chicken Cheesesteak – currently containing an astounding 7795mg of sodium – would you continue to invite adverse publicity via online ‘worst-of’ lists and in-store warning labels, or instead dial down salt, perhaps even phasing out the item from sale? Reformulated recipes rolled out by national chains may benefit millions of fast food customers far beyond New York City. Even before the potential ‘domino effect’ when emboldened health authorities elsewhere copy the measure, the little salt-shaker icon could have significant flow-on effects.

But what is an amount of salt worth warning us about? Burger industry representatives have been quick to proclaim most burgers in NYC wouldn’t be slapped with warnings under the current threshold. One whole teaspoon is a high bar if applied only to individual items. If a similar measure were applied in Australia, we may not see too many salt-shakers appear, though KFC’s Zinger Stacker burger comes dangerously close. Thankfully the law also applies to advertised meal combinations – in case you needed it, one more incentive not to ‘super-size me’.

Perhaps an entire day’s total is still an unreasonably high benchmark. If we allow food companies to market packaged foods as a ‘good source’ of positive nutrients like protein or fibre when containing just 20% of the daily recommended intake, and an ‘excellent’ source at 50% – why not apply a similar metric to a warning when the reverse is true?

Even if items don’t qualify for a salt-shaker, few would argue most products sold by these chains are ‘good for you’. Some point to limitations of focusing on single nutrient warnings, but such critiques miss the intervention’s place as only one component of a suite of complementary measures (including voluntary salt reformulation programs and trans-fat bans) which operate together to improve the food environment and enable consumers to make healthier choices.

In NYC – just as in New South Wales – total energy content is already displayed for all menu items. Results from NSW have been encouraging: the Food Authority found a 15% decrease in average kilojoules purchased. Despite a recent high-profile breach by McDonalds’ on its new digital menu boards, compliance has generally been high. Laws exist only in NSW, South Australia and the ACT, but many national chains have rolled out kilojoule information nationwide, delivering benefits to countless Australians.

As NSW considers extending menu labels to cover additional nutrients, New York’s salt-shaker provides global leadership. Perhaps better still, Australia has already developed a system combining information on a variety of risk factors (salt, sugar and saturated fat) with positive nutrients and total energy content into a single interpretive symbol. If ‘Health Star Ratings’ prove popular on front-of-pack of packaged foods in our supermarkets, why not extend them to fast food?

Further Reading: