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:

Upcoming Conferences: Emerging Health Policy Research Conference 2015

The Menzies Centre for Health Policy is hosting its 10th annual Emerging Health Policy Research Conference on Tuesday, 21 July 2015, at the University of Sydney.

The Conference showcases the work of current masters, doctoral and early career research workers, as well as those new to the field of health policy research. This year’s keynote speaker is Professor Billie Giles-Cori, Director of the McCaughey VicHealth Community Wellbeing Unit, Centre for Health Equity, University of Melbourne. The conference includes sessions on healthy environments, research translation, health systems and workforce, policy analysis, and mental health.

The full conference program and registration form are available on the Menzies Centre website.

Australia gets a D- in chronic disease prevention

Writing in The Age earlier this month, Professor Rob Moodie gave the Australian Federal Government a failing grade for its efforts in non-communicable disease prevention. According to Professor Moodie, Australia’s preventive health agenda ‘is in serious trouble’ and ‘there’s a grave risk of it disappearing altogether.’

Professor Moodie’s assessment draws upon a recent report from the Mitchell Institute of Health and Education Policy at Victoria University, authored by Sharon Wilcox. This report maps out the social, economic and health costs of chronic diseases to the Australian community, and identifies evidence on the cost-effectiveness of interventions to prevent chronic disease (a second report identifies strategic priorities for taking action in preventive health). This blog post uses the Mitchell Institute’s report as the basis for an assessment of Australia’s progress in NCD prevention, focusing on the Federal Government’s response to the World Health Organisation’s  (WHO) Global Action Plan for the Prevention and Control of NCDs, and the government’s response to the report of the National Preventive Health Taskforce in 2009.

The Global Action Plan for the Prevention and Control of NCDs 2013-2020

In September 2011 the United Nations devoted a high level summit to NCDs, which led to the adoption of the Political Declaration on the Prevention and Control of Non-Communicable Diseases. In 2012 the WHO set the global target of a 25% reduction in premature NCD mortality by 2025 (the ’25×25′ goal), and a year later it adopted the Global Action Plan for the Prevention and Control of NCDs 2013-2020. The Global Action Plan provides a road map and menu of policy options for states and other actors to reduce the burden of NCDs. It also sets out a global monitoring framework, including nine voluntary global targets and 25 indicators for tracking progress towards achieving the voluntary targets, with reporting due in 2015 and 2020. The action plan anticipates that states will develop policies and set national targets for chronic disease prevention, and monitor their progress against agreed indicators.

The National Preventative Health Taskforce

In 2008 the Federal Labor Government established the National Preventive Health Taskforce (NPHT), and charged it with developing strategies to tackle the health challenges posed by tobacco, alcohol, and obesity. Following a process of consultation and review, the Taskforce released its final report in September 2009, entitled Australia: The Healthiest Country by 2020. The report comprised five documents, and put forward 136 recommendations and 35 areas for action, focusing on preventive measures for tackling obesity, tobacco and alcohol, as well as developing critical prevention infrastructure.

The Taskforce set four main goals for prevention by 2020, and identified seven strategic directions for effective implementation of its recommendations, including shared responsibility between different government and non-government actors; engaging communities; influencing markets and developing connected and coherent policy; reducing inequality; ‘closing the gap’ for Indigenous Australians and refocusing primary care towards prevention.

The Taskforce proposed action that encouraged individuals to adopt healthy lifestyles, but also targeted the social, cultural, and economic environments that shape individual choices on tobacco, alcohol, and unhealthy food consumption. Using a phased approach, the report recommended the introduction of a range of measures to reshape unhealthy environments, including: interpretive food labelling on packaged foods and fast-food restaurant menus; restricting food advertising to children; expanding restrictions on tobacco promotion and mandating plain packaging; protecting young people from exposure to alcohol advertising, and introducing a minimum floor price for alcoholic beverages.

In 2010 the Federal Government released its response to the Taskforce’s report, called Taking Preventive Action: A Response to Australia: The Healthiest Country by 2020.  The government addressed 68 of the Taskforce’s recommendations, and considered a further 49. The government identified 15 recommendations as the responsibility of state and territory governments, and stated that four other recommendations were not consistent with government policy. The final sections of this post discuss the government’s response to the NPHT’s recommendations for specific initiatives related to obesity, tobacco and alcohol.

In relation to preventative health infrastructure, the government had established the National Partnership Agreement (NPA) on Preventive Health prior to the release of the Taskforce’s final report, to which it allocated $872.1 million for investment in prevention initiatives, including community-based programs and local policies that support healthy eating and physical activity. States and territories also agreed to report on progress in reducing the prevalence of unhealthy weight, smoking, physical inactivity and poor nutrition through the NPA.

The government established the Australian National Preventive Health Agency (ANPHA) in response to the NPHT’s report, an independent statutory authority that was to coordinate the government’s response to the report of the NPHT, and which was funded through the NPA. The work of the ANPHA included monitoring and evaluating national prevention policies and programs; advising COAG on national priorities and options for preventative health; administering national programs, and facilitating national partnerships, and advising on national infrastructure for surveillance, monitoring, research and evaluation.

Australia’s 2014 report on implementation of the Global Action Plan 

Australia is a signatory to the WHO’s Global Action Plan on NCD Prevention, and made submissions contributing to its development. Australia also provided information in 2010 and 2014 on its capacity to address chronic diseases.

In 2014, Australia self-assessed its capacity to respond to chronic diseases as relatively strong, on the basis that it had a national systems response to NCDs, an operational NCD unit within the Department of Health, and a multisectoral national policy on NDCs, accompanied by policies on specific NCD risk factors – the harmful use of alcohol, physical inactivity, unhealthy diets, and tobacco use. However, the government indicated that it did not have an NCD surveillance and monitoring system to enable reporting against the nine global NCD targets.

The Mitchell report concludes that there is a lack of comprehensive, public reporting on how well Australia is tackling NCDs. Australia has established targets and indicators in line with its commitments under the Global Action Plan, via the NPA on Preventive Health and the National Health Performance Authority’s Performance and Accountability Framework. The latter identifies indicators against which the performance of public hospitals and primary health care organisations are measured, some of which relate to the risk factors for NCDs. However, together these amount to a relatively narrow suite of indicators. Despite the Global Action Plan including measurable targets for six key risk factors, Australian indicators focus on smoking, physical activity, body weight and the consumption of fruits and vegetables, excluding targets for tackling harmful alcohol use, reducing salt intake, and blood pressure.

The NPA on Preventive Health required states and territories to provide reports outlining performance against benchmarks as at 30 June 2013 and 31 December 2014, but there was no requirement for the reports to be made public, thus significantly reducing the accountability of the targets, according to the Mitchell Institute report.  The COAG Reform Council had responsibility for monitoring the performance of various national partnership agreements in Australia, but it did not publish any analyses of progress under the NPA on Preventive Health. The Council’s final report on the National Healthcare Agreement  described data for two of the performance benchmarks in the NPA, noting that smoking rates had fallen significantly, but not sufficiently to meet the benchmark of reducing smoking rates to 10% by 2019. The report also mentioned that there was no significant change in the proportion of adults or children at a healthy body weight between 2007-08 and 2011-2012.

Two steps forward and one step back: rescinding prevention funding and abolishing infrastructure

Australia’s capacity to address NCDs is critically impaired by reforms under the Federal Abbot Liberal Government, which has dismantled prevention infrastructure introduced by the previous Labor government in response to the report of the NPHT, and it has also rescinded funding for prevention initiatives. In its 2014-15 Budget, the government indicated that it would:

  • Abolish the COAG Reform Council;
  • Abolish the ANPHA; and
  • Cease funding the NPA on Preventive Health

These changes mean the loss of  $386 million in funding for various prevention agreements made between the Federal Government and the states, and imply that there is no longer dedicated, specific national funding for the prevention of chronic disease. The status and commitment of governments to targets under the NPA on Preventive Health is now uncertain, and the abolition of the NPA and the ANPHA remove key mechanisms for coordinating state and Federal Government action on preventive health. The abolition of the ANPHA and the COAG Reform Council also critically impairs national monitoring and reporting on targets for the prevention of chronic diseases.

The Mitchell report notes other limitations in the Federal Government’s response to prevention, including the absence of a comprehensive, coordinated policy framework for prevention, and a lack of current estimates or recent trend data on the morbidity and mortality rates associated with chronic diseases (although it notes that there has been some investment in new research and expanded datasets, including the expansion of the Australian Health Survey in 2011-12 to include additional data on nutrition, physical activity and biomedical measures).

A failure to take action on many of the NPHT’s recommendations 

The Federal Government has failed to act on many of the recommendations for prevention initiatives from the NPHT in relation to reducing obesity, tobacco use and excessive alcohol consumption, which were meant to accompany the expansion of government infrastructure for prevention. There were some promising first steps following the Taskforce’s report, including an increase of 25% in tobacco excise from April 2010; harmonising tax rates for alcopops with other spirit-based drinks, and the introduction of tobacco plain packaging laws, which took effect in 2012. However, many of the NPHT’s other recommendations have not been implemented, including greater restrictions on promoting alcohol at times or locations where young people are likely to be exposed to such promotions, and the introduction of health impact assessments by governments across all policies.

My own research, undertaken together with Professor Roger Magnusson, shows that where the government has acted on the NPHT’s recommendations, it has often chosen the weakest regulatory option available. The Federal Government encouraged the food industry to create its own voluntary codes on marketing food to children, despite the Taskforce recommending legislation that banned unhealthy food promotions before 9pm on television. The government supported a voluntary ‘health star rating system’ for food labelling, giving in to industry lobbying against the traffic light labelling system proposed by health advocates. Through the Food and Health Dialogue the government has established a platform for voluntary collaboration between industry, government and public health organisations on a program of product reformulation, which, although promising, lacks transparency and accountability.

The government remains committed to industry engagement and voluntary action, despite evidence that such initiatives produce very limited improvements at best, and that many such programs lack the design features of successful voluntary programs.

Where to from here?

The Federal Government’s inaction on NCDs is frustrating, because much of this burden of death and disease is preventable, and often at relatively little cost. The risk factors for NCDs are well known, and the WHO has identified series of “best buys” for tackling NCDs, i.e. effective, feasible policies that are affordable for most countries. Australian research has also evaluated the cost-effectiveness of a suite of preventive measures, and has identified promising opportunities for action, including increasing taxes on alcohol and tobacco by 30%, taxing unhealthy foods by an additional 10%, and mandatory limits for the salt content of processed food.

Many of these measures require legislative or regulatory reform in order to be implemented by government. Legislative change aimed at NCD prevention is often put into the ‘too hard’ basket in Australia, with even those supporting public health reforms claiming that it can’t be done. But many countries are experimenting with novel legislative and regulatory measures to address NCDs, including mandatory limits on the salt content of processed foods in South Africa, co-regulatory restrictions on junk food marketing to children in the United Kingdom, and a one peso per litre tax on soft drink in Mexico.

These examples show that strong government intervention to prevent NCDs is not outside the realm of possibility, and that Australia is fast becoming a ‘laggard’ in NCD prevention, despite its world-class track record in tobacco control. Future blog posts will further explore Australia’s efforts in chronic disease prevention, and identify avenues for action, including novel forms of regulation aimed at promoting healthy lifestyles, and legal mechanisms for strengthening existing voluntary initiatives favored by the Federal Government.