Despite industry objections, alcohol and pregnancy warnings will be mandatory in Australia and New Zealand

The food regulator, Food Standards Australia New Zealand (FSANZ) has finalised the form of the alcohol and pregnancy warning label that will be mandatory on packaged alcohol sold in both countries.

Assuming the States do not request a further review, the new warning will be added as an amendment to Standard 1.2.7 of the Food Standards Code and will become mandatory after a two year transition period (see pp 6, 78 here).

Here it is.

It’s been a long time coming

In 2011, the Australian and New Zealand Food Regulation Ministerial Council commissioned a review of food labelling law and policy, chaired by Neil Blewett AC.

The committee’s report, co-authored by Australian public health law pioneer Chris Reynolds, is a terrific document, although increasingly difficult to locate online.

The Committee saw no reason to exempt alcohol from labelling requirements, in view of evidence relating to the risks of binge drinking and longer-term over-consumption.

(In 2015, alcohol use was responsible for more than 6,300 deaths in Australia, or 4% of total deaths – see AIHW, Australian Burden of Disease Study 2015, Table D2, p 167)

Amongst many sensible recommendations, the report recommended that “generic alcohol warning messages should be placed on alcohol labels” as part of a broader, multifaceted, national campaign addressing alcohol-related harm [recommendation 24].

Secondly, it recommended that a mandatory warning about the risks of drinking while pregnant should be included on “containers of alcoholic beverages and at point of sale for unpackaged alcoholic beverages” [recommendation 25].

Thirdly, it recommended that alcoholic beverages should not be exempt from energy labelling requirements that apply to packaged food under Standard 1.2.8 of the Food Standards Code [recommendation 26].

The Government’s response to the review is here.

Added momentum for a warning label about the risks of drinking while pregnant came from a Parliamentary inquiry in 2012 into the Prevention, Diagnosis and Management of Fetal Alcohol Spectrum Disorders.

The Foreword to this report, from the House of Representatives Standing Committee on Social Policy and Legal Affairs, states:

“FASD [fetal alcohol spectrum disorders] is an entirely preventable but incurable condition caused by a baby’s exposure to alcohol in the womb. The consequences are expressed along a spectrum of disabilities including: physical, cognitive, intellectual, learning, behavioural, social and executive functioning abnormalities and problems with communication, motor skills, attention and memory.”

The lifetime cost of for one person with FASD in the United States is at least UD$2 million (see FASD Strategic Action Plan 2018-2028, p 8).

The Standing Committee recommended that the Commonwealth implement – by 1 October 2013 – a mandatory warning label advising women not to drink when pregnant or planning a baby on packaging of all pregnancy test kits (Recommendation 7).

This recommendation has not been implemented.

The Committee also recommended implementation – by 1 January 2014 – of a warning label for all alcoholic beverages advising women not to drink while pregnant or planning pregnancy (Recommendation 11).

FSANZ has now finalized this warning – for packaged alcohol.  A warning about drinking while breastfeeding was outside the scope of this work.

It should have been a non-brainer

The Australian Institute of Health and Welfare reports that in 2016, around 35% of Australian women drank while pregnant.  One in four women who were unaware of their pregnancy continued to drink after they found out.

In this age of personal responsibility, alcohol and pregnancy warning labels ought to be a no-brainer, but it has taken until 31 January 2020 for Food Standards Australia New Zealand to approve a mandatory health warning and graphic for alcoholic beverages that contain more than 1.15% alcohol by volume.

For detail of the amendment to Standard 2.7.1, which governs labelling of alcoholic beverages, see here (pp 100-104).

The Australian and New Zealand Ministerial Forum on Food Regulation, which is responsible for developing food regulation policy, had earlier, in October 2018, requested FSANZ to consider options for mandatory alcohol and pregnancy warning labels.

Getting FSANZ involved was a good idea – long overdue.  FSANZ is a technical, a-political agency that reviews evidence, considers options and develops the mandatory technical standards that make up the Food Standards Code.

A methodical, evidence-based, bureaucratic process has significant advantages in areas of regulation prone to lobbying and interference from well-resourced industries.

The internet remembers

Draft (updated) National Health and Medical Research Council (NHMRC) Guidelines clearly state:

“A To reduce the risk of harm to their unborn child, women who are pregnant or planning a pregnancy should not drink alcohol.

B For women who are breastfeeding, not drinking is safest for their baby.” (p 47)

In 2018, DrinkWise, a responsible drinking campaign largely funded by the alcohol industry, distributed a poster to hospitals and GP clinics around the country that said: “It’s not known if alcohol is safe to drink when you are pregnant”.

This was widely criticised; even the New York Times ran a story.

DrinkWise re-phrased its poster (see below).

DrinkWise now has a new campaign called “The internet remembers”.

Indeed.

Alcohol industry objections

The Approval Report for the new warning label lists the concerns raised by the alcohol industry, together with FSANZ’ response.  The warning FSANZ chose was: “Alcohol can cause lifelong harm to your baby” – which performed better in consumer testing than “Any amount of alcohol can harm your baby”.

For its part, the alcohol industry suggested that the text of the warning should be “It’s safest not to drink while pregnant” as “medical knowledge is not settled whether drinking small amounts [while pregnant] has a bad influence [on the foetus] (see p 44 here).

Industry was also concerned that the words “HEALTH WARNING” were “misleading, inflammatory and may alarm consumers” (p 26).  It recommended changing “HEALTH WARNING” to “DRINK RESPONSIBLY” (p 28).

FSANZ noted, unsurprisingly, that such a change would “not meet the intended purpose of the pregnancy warning label to reinforce public health advice and messaging not to drink alcohol while pregnant”.

Industry also objected to the red font required for “HEALTH WARNING”, on the basis that it would inflate costs.  It requested a monochromatic label (p 44).  It wanted the label to be smaller (p 29).  It felt the cost of the label was not proportionate to the benefit (pp 33-34).

Industry sought a longer phase-in period of up to 5 years, rather than the 2 years proposed by FSANZ (p 36).

Overall, while the alcohol industry was “fully supportive of interventions that are proportionate, well evidenced and shown to be effective at changing harmful consumption behaviours”, it was “concerned about the lack of rigour of the proposal in this regard” (p 43).

Its objections even extended to the ponytail in the graphic of the woman (p 24).

Overall, the impression you get is of an industry keen to reduce the consumer impact of the warning, keen to delay its implementation, and far more interested in revenue than the harm its products can cause the next generation.

No surprises there, unfortunately.

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: