Well, who would have thought that front-of-pack labelling (FoPL) would come around again so quickly in the contested public health policy space? It seems like only yesterday that all the major parties to the debate were welcoming the new Health Star Rating (HSR) system and the end of a protracted impasse between the food industry and the public health sector arising from their opposing views on the “interpretive” versus “informative” FoPL formats.
A determined political push, leadership from the Commonwealth, some fancy statistical footwork from some key industry and FSANZ staff, and a genuine spirit of goodwill broke the impasse leading to the introduction of the intuitive HSR FoPL system in mid-2014.


The collective sigh of relief from the major stakeholders was palpable as the five-year trial period for the voluntary system seemed to stretch way into the distant future (or at least until mid-2019). It was recognised from the launch that the HSR system was not perfect – in fact, in its development the catch-cry "don't let the perfect be the enemy of the good" guided much of the decision making. And all-in-all most commentary on the release of the HSR and immediately after was positive. The more naïve (myself included) assumed the goodwill and desire to make the system work would continue and a period of cooperation between stakeholders would extend into the formal review period of the HSR System, which is now underway. But alas, the uneasy alliances, did not last and the “imperfect has become the enemy of the good”.
The three years since the HSR release has witnessed a number of academics publishing studies bagging the HSR, and more in recent months. I have commented before in these pages that those academics have missed the point – they don't understand the role of the HSR labelling system as a public health intervention. It's designed to guide food choices resulting in better diets aligned to the Australian Dietary Guidelines (ADG). Simply, if a lot of products carry the HSR labelling, and if many consumers choose higher star rating products more often than not, diets at a population level will align more closely with the ADG. That is, there will be lower intakes of risk-associated nutrients and more of positive nutrients. It has never been claimed that the HSR provides a definitive, technically perfect assessment of the healthiness of a food product. Indeed, those imagining such a perfect system can be constructed are misguided in the extreme.


Of course, allowing the terms “healthy” foods and “unhealthy” foods to creep into common parlance has undermined the important concept of healthy and unhealthy diets and the intake of nutrients as the key determinants of nutritional health. Recently this good food/bad food myth has become cloaked in respectability through the terminology of “discretionary” and “core foods”. These terms have some utility in identifying the fit for purpose of foods (ie occasional treat foods vs meal time foods), but unfortunately this practical use has been high-jacked to drive food philosophies – essentially an anti-processed food, anti-food industry push. And now we see the same critics seeking to co-opt the HSR system to their misguided dogmas.

 

The most recent example is a paper by Peters et al 2017, which reports that when “added sugars” are substituted for “total sugars” in the HSR algorithm its discrimination between discretionary foods and core foods is
“improved”. Now this finding should come as no surprise due to the circularity between the HSR algorithm and the classification of foods as discretionary and core.

 

The authors report “foods were classified as core or discretionary as per the Australian Dietary Guidelines”. The Australian Dietary Guidelines classify discretionary foods based on their added sugars (and other riskassociated
nutrients). Now I have never claimed to be an expert in experimental study design or statistics, but I can see self-serving logic when it leaps from the page. Switching “added sugars” into the HSR algorithm and then claiming that it
improves discrimination between core and discretionary foods, which have themselves been defined based on their added sugar content, is an entirely predictable outcome. Quite frankly, I’m surprised this rudimentary problem with the study survived the journal’s editors.


Of course, the authors would argue that the HSR system should be optimised to identify discretionary foods, but that diminishes its core function of helping consumers to choose food products within food categories, including core foods.

 

In the paper the authors go on to advocate for added sugars to be used in the HSR algorithm within the context of the five-year HSR review. They add to their argument by falsely implying the World Health Organization recommendations regarding “free sugars” apply to added sugars when they do not. Space does not allow me to give a comprehensive description of the distinction, but suffice to say that free sugars as defined by WHO are closer to the total sugars used in the HSR and in the current requirements in the ANZ Food Standards Code regarding the Nutrition Information Panel sugars declaration and the Nutrient Profiling Scoring Criterion (NPSC) in Standard 1.5.7 Nutrition, Health and Related Claims.

 

In fact, development of each of the [related] algorithms used by the HSR, the NPSC, and United Kingdom’s Ofcom all considered and rejected added sugars as a component in favour of total sugars. And for much the same reasons. The body treats all sugars in much the same way (a sugar molecule is a sugar molecule
no matter how it’s packaged), and indeed added sugars are difficult to measure directly (a point the Peter et al concede when discussing the limitations of their paper). Getting back to the HSR review and ultimate purpose of the HSR system, which is to assist consumers to eat more healthily, a collegiate approach and a collaborative effort aimed at refining the HSR and building on its already impressive track record (7000 products, high levels of consumer awareness) would help. I am encouraged by the Health Star Rating Advisory Committee stressing that any change in the HSR system will be based on a solid evidence base. Indeed, the Australian Food & Grocery Council and its members will not accept anything less.

 

Words by Geoffrey Annison PHD
Australian Food & Grocery Council